Healthcare Provider Details

I. General information

NPI: 1316114564
Provider Name (Legal Business Name): GWENDOLYN HOLDINESS PROCTOR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2008
Last Update Date: 09/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 N 18TH ST SUITE A
MONROE LA
71201-4420
US

IV. Provider business mailing address

130 DESIARD ST STE 355
MONROE LA
71201-7319
US

V. Phone/Fax

Practice location:
  • Phone: 318-807-3700
  • Fax: 318-807-0014
Mailing address:
  • Phone: 318-807-7875
  • Fax: 318-812-9997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number204506
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: