Healthcare Provider Details

I. General information

NPI: 1003417023
Provider Name (Legal Business Name): KENNETH EARL GWINN JR. FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2020
Last Update Date: 11/05/2020
Certification Date: 10/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

176 MEDICAL CENTER DR
RAINELLE WV
25962-1064
US

IV. Provider business mailing address

176 MEDICAL CENTER DR
RAINELLE WV
25962-1064
US

V. Phone/Fax

Practice location:
  • Phone: 304-438-6188
  • Fax:
Mailing address:
  • Phone: 304-438-6188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number107635
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: