Healthcare Provider Details

I. General information

NPI: 1790728962
Provider Name (Legal Business Name): GWEN B ENFIELD RD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 05/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 MEASE DR SUITE 410
SAFETY HARBOR FL
34695-6602
US

IV. Provider business mailing address

PO BOX 743409
ATLANTA GA
30374-3409
US

V. Phone/Fax

Practice location:
  • Phone: 727-734-6888
  • Fax: 727-266-4913
Mailing address:
  • Phone: 727-532-0002
  • Fax: 727-266-4928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberND216
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: