Healthcare Provider Details

I. General information

NPI: 1528846052
Provider Name (Legal Business Name): KATHERINE NICOLE GWIN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2023
Last Update Date: 09/18/2023
Certification Date: 09/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 MARTINIQUE CV
NICEVILLE FL
32578-3832
US

IV. Provider business mailing address

405 MARTINIQUE CV
NICEVILLE FL
32578-3832
US

V. Phone/Fax

Practice location:
  • Phone: 850-687-5615
  • Fax:
Mailing address:
  • Phone: 850-687-5615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND6642
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLDN0000004549
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: