Healthcare Provider Details

I. General information

NPI: 1194190025
Provider Name (Legal Business Name): MANDY L GWIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MANDY L WOLFGANG

II. Dates (important events)

Enumeration Date: 12/03/2015
Last Update Date: 12/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 WATERFORD ST
EDINBORO PA
16412-5517
US

IV. Provider business mailing address

1100 SHAWNEE ROAD
LIMA OH
45805
US

V. Phone/Fax

Practice location:
  • Phone: 814-734-5021
  • Fax: 814-734-1433
Mailing address:
  • Phone: 419-999-2030
  • Fax: 419-991-0909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberTEI001465
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: