Healthcare Provider Details

I. General information

NPI: 1972551497
Provider Name (Legal Business Name): GWENDOLYN K KNOTTS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7675 STERLING AVE
SAN BERNARDINO CA
92410-4738
US

IV. Provider business mailing address

742 W HIGHLAND AVE
SAN BERNARDINO CA
92405-3839
US

V. Phone/Fax

Practice location:
  • Phone: 909-381-8983
  • Fax: 909-381-2933
Mailing address:
  • Phone: 909-881-7320
  • Fax: 909-881-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberRN250278
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: