Provider Demographics
NPI:1124543822
Name:NIELSEN, GWEN (RPH)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2536 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-5456
Mailing Address - Country:US
Mailing Address - Phone:307-237-2215
Mailing Address - Fax:
Practice Address - Street 1:700 S GREELEY HWY
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82007-2848
Practice Address - Country:US
Practice Address - Phone:307-635-7877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-03
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY2442183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist