Healthcare Provider Details

I. General information

NPI: 1750581229
Provider Name (Legal Business Name): GWENDOLYN BALL FISHER FNP, MPH, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2007
Last Update Date: 05/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 ROANOKE BLVD
SALEM VA
24153-6404
US

IV. Provider business mailing address

1970 ROANOKE BLVD
SALEM VA
24153-6404
US

V. Phone/Fax

Practice location:
  • Phone: 540-982-2463
  • Fax: 540-855-3402
Mailing address:
  • Phone: 540-982-2463
  • Fax: 540-855-3402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number14626
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number055681
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: