Healthcare Provider Details

I. General information

NPI: 1598752156
Provider Name (Legal Business Name): GWEN E RICHARDSON PHD CFNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 STADIUM MALL DR
WEST LAFAYETTE IN
47907-2052
US

IV. Provider business mailing address

601 STADIUM MALL DR
WEST LAFAYETTE IN
47907-2052
US

V. Phone/Fax

Practice location:
  • Phone: 765-494-1700
  • Fax: 765-496-1227
Mailing address:
  • Phone: 765-494-1700
  • Fax: 765-496-1227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28105011A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71000365A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: