Healthcare Provider Details

I. General information

NPI: 1023074465
Provider Name (Legal Business Name): GWENDOLEN WOOD PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7501 QUAKER AVE
LUBBOCK TX
79424-3367
US

IV. Provider business mailing address

5219 CITY BANK PKWY STE 35
LUBBOCK TX
79407-3544
US

V. Phone/Fax

Practice location:
  • Phone: 806-793-7257
  • Fax: 806-799-1568
Mailing address:
  • Phone: 806-785-7676
  • Fax: 806-785-7685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number507591
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: