=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043783665
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GWENDOLYN WLLIAMS CNA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2019
-----------------------------------------------------
Last Update Date | 01/07/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 538 WILLIAMSBURG RD
-----------------------------------------------------
City | WEWAHITCHKA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32465-4508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-287-9969
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 538 WILLIAMSBURG RD
-----------------------------------------------------
City | WEWAHITCHKA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32465-4508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-287-9969
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 376K00000X
-----------------------------------------------------
Taxonomy Name | Nurse's Aide
-----------------------------------------------------
License Number | 271097
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------