Provider Demographics
NPI:1043442254
Name:STEWART, GWENDOLYN J (DNP, FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:J
Last Name:STEWART
Suffix:
Gender:F
Credentials:DNP, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1907 MISSION 66
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-3711
Mailing Address - Country:US
Mailing Address - Phone:601-636-1173
Mailing Address - Fax:
Practice Address - Street 1:1420 VICEROY DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-2208
Practice Address - Country:US
Practice Address - Phone:214-358-2300
Practice Address - Fax:214-366-6159
Is Sole Proprietor?:No
Enumeration Date:2009-08-20
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP118552363LF0000X, 363L00000X
TX1192363LF0000X
MSR881390363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08602226Medicaid
TXAP118552OtherNURSE PRACTITIONER