Healthcare Provider Details

I. General information

NPI: 1396135539
Provider Name (Legal Business Name): SUSAN MICHELE GWINN APRN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2015
Last Update Date: 01/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605 MACCORKLE AVE SW
SOUTH CHARLESTON WV
25309-1311
US

IV. Provider business mailing address

4605 MACCORKLE AVE SW
SOUTH CHARLESTON WV
25309-1311
US

V. Phone/Fax

Practice location:
  • Phone: 304-766-3967
  • Fax: 304-766-4392
Mailing address:
  • Phone: 304-766-3967
  • Fax: 304-766-4392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number45024
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: