Healthcare Provider Details

I. General information

NPI: 1720461817
Provider Name (Legal Business Name): MANDY L GWALTNEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 07/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7540W BROWN RD
MANISTIQUE MI
49854-9555
US

IV. Provider business mailing address

7540W BROWN RD
MANISTIQUE MI
49854-9555
US

V. Phone/Fax

Practice location:
  • Phone: 906-341-5975
  • Fax:
Mailing address:
  • Phone: 906-341-5975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: