Healthcare Provider Details

I. General information

NPI: 1073285581
Provider Name (Legal Business Name): MGM-MEDICAL GOALS MANAGEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2021
Last Update Date: 04/17/2022
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1732A MARSH RD STE 216
WILMINGTON DE
19810-4606
US

IV. Provider business mailing address

1732A MARSH RD STE 216
WILMINGTON DE
19810-4606
US

V. Phone/Fax

Practice location:
  • Phone: 610-405-1292
  • Fax:
Mailing address:
  • Phone: 610-405-1292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: GWENDOLYN SUMTER-DAVIS
Title or Position: CEO
Credential: CRNP
Phone: 610-405-1292