=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437931078
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GWENDOLYN GANNON RN-BC, CRRN, CCM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2023
-----------------------------------------------------
Last Update Date | 10/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16030 CARNATION DR
-----------------------------------------------------
City | PUNTA GORDA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33955-7156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-813-4100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2111 WILSON RUN RD
-----------------------------------------------------
City | WALLINGFORD
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41093-8955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-813-4410
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WC0400X
-----------------------------------------------------
Taxonomy Name | Case Management Registered Nurse
-----------------------------------------------------
License Number | 2833022
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------