Provider Demographics
NPI:1033382213
Name:RIDDELL, GWENDOLYN R (CNM, APN)
Entity Type:Individual
Prefix:MS
First Name:GWENDOLYN
Middle Name:R
Last Name:RIDDELL
Suffix:
Gender:F
Credentials:CNM, APN
Other - Prefix:
Other - First Name:GWEN
Other - Middle Name:
Other - Last Name:RIDDELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CNM, APN
Mailing Address - Street 1:206A BOYCE ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-5426
Mailing Address - Country:US
Mailing Address - Phone:707-545-4675
Mailing Address - Fax:707-547-2229
Practice Address - Street 1:1140 SONOMA AVE STE 3
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4817
Practice Address - Country:US
Practice Address - Phone:707-766-4276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-08
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANMW1802176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILMR1235438OtherDEA