Provider Demographics
NPI:1073157293
Name:GWYNN, WENONAH
Entity Type:Individual
Prefix:
First Name:WENONAH
Middle Name:
Last Name:GWYNN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 PUMPHREY DR
Mailing Address - Street 2:
Mailing Address - City:FORESTVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20747-4308
Mailing Address - Country:US
Mailing Address - Phone:301-735-5741
Mailing Address - Fax:301-877-1181
Practice Address - Street 1:3333 PUMPHREY DR
Practice Address - Street 2:
Practice Address - City:FORESTVILLE
Practice Address - State:MD
Practice Address - Zip Code:20747-4308
Practice Address - Country:US
Practice Address - Phone:301-735-5741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-31
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16AL1226-A310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
16AL1226-AOtherOHCQ
MD16AL1226-AOtherOHCQ