Healthcare Provider Details

I. General information

NPI: 1316705882
Provider Name (Legal Business Name): MARY KATE GWOZDZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2024
Last Update Date: 03/11/2024
Certification Date: 03/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 SUNSET VIEW RD
SOUTH HERO VT
05486-4503
US

IV. Provider business mailing address

19 SUNSET VIEW RD
SOUTH HERO VT
05486-4503
US

V. Phone/Fax

Practice location:
  • Phone: 508-717-7846
  • Fax:
Mailing address:
  • Phone: 508-717-7846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number026.0136914
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: