Healthcare Provider Details

I. General information

NPI: 1912763053
Provider Name (Legal Business Name): ANN GWINN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2024
Last Update Date: 04/30/2024
Certification Date: 02/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 W POPLAR ST
WALLA WALLA WA
99362
US

IV. Provider business mailing address

209 W POPLAR ST
WALLA WALLA WA
99362-2828
US

V. Phone/Fax

Practice location:
  • Phone: 509-897-8600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberNC10002400
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: