Healthcare Provider Details

I. General information

NPI: 1174397368
Provider Name (Legal Business Name): KATHRYN GWYNN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2023
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 BRAMHALL ST
PORTLAND ME
04102-3175
US

IV. Provider business mailing address

22 BRAMHALL ST
PORTLAND ME
04102-3175
US

V. Phone/Fax

Practice location:
  • Phone: 207-662-2526
  • Fax:
Mailing address:
  • Phone: 207-662-2526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN741544
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number6972255-3102
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA233079
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: