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NPI Code Detail

MEDICARE: MS. GWENDOLYN GIST MS/LSW

MEDICARE: MS. GWENDOLYN GIST MS/LSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1171M00000XCase Manager/Care CoordinatorOH

General Provider Information

NPI Number : 1093349755
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. GWENDOLYN GIST MS/LSW
Provider Business Mailing Address
First Line : 133 WAVERLY AVE
Second Line :
City : DAYTON
State : OH
Zip : 45405-2231
Country : US
Telephone Number : 937-409-0045
Fax Number :
Provider Business Practice Location Address
First Line : 117 ASHWOOD AVE
Second Line :
City : DAYTON
State : OH
Zip : 45405-2643
Country : US
Telephone Number : 937-221-8003
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/02/2020
Last Update Date : 03/02/2020

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