Healthcare Provider Details

I. General information

NPI: 1972963304
Provider Name (Legal Business Name): GWENDOLYN LORRAINE WATFORD R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2016
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6609 RACQUET CLUB DR
LAUDERHILL FL
33319-1807
US

IV. Provider business mailing address

6609 RACQUET CLUB DR
LAUDERHILL FL
33319-1807
US

V. Phone/Fax

Practice location:
  • Phone: 860-729-4711
  • Fax:
Mailing address:
  • Phone: 860-729-4711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9501558
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: