Provider Demographics
NPI:1073173183
Name:BOOTH, GWENDOLYN MEREDITH (RN)
Entity Type:Individual
Prefix:MISS
First Name:GWENDOLYN
Middle Name:MEREDITH
Last Name:BOOTH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29008 GLADIOLUS DR
Mailing Address - Street 2:
Mailing Address - City:CANYON COUNTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91387-1828
Mailing Address - Country:US
Mailing Address - Phone:661-600-8328
Mailing Address - Fax:
Practice Address - Street 1:2900 E DEL MAR BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-4375
Practice Address - Country:US
Practice Address - Phone:626-795-9901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA845947163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health