Provider Demographics
NPI:1023374139
Name:WREN, GWENDOLYN ANN (CACDP)
Entity Type:Individual
Prefix:MS
First Name:GWENDOLYN
Middle Name:ANN
Last Name:WREN
Suffix:
Gender:F
Credentials:CACDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2459 PARKER ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48214-1824
Mailing Address - Country:US
Mailing Address - Phone:313-743-2540
Mailing Address - Fax:
Practice Address - Street 1:13336 E WARREN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48215-2112
Practice Address - Country:US
Practice Address - Phone:313-822-6940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133NN1002X
MI133N1002X133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education