Healthcare Provider Details

I. General information

NPI: 1194864330
Provider Name (Legal Business Name): MISS GWENDOLYN WORSHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

893 HIGHWAY 64
AUGUSTA AR
72006-5119
US

IV. Provider business mailing address

1101 WOODRUFF
AUGUSTA AR
72006
US

V. Phone/Fax

Practice location:
  • Phone: 870-347-5906
  • Fax: 870-347-1457
Mailing address:
  • Phone: 870-347-1436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: