Provider Demographics
NPI:1144564246
Name:PHINISEE, GWENDOLYN (RN)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:PHINISEE
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 1:1102 MACKIN RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-1204
Mailing Address - Country:US
Mailing Address - Phone:810-257-3676
Mailing Address - Fax:810-257-0713
Practice Address - Street 1:1102 MACKIN RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-1204
Practice Address - Country:US
Practice Address - Phone:810-257-3676
Practice Address - Fax:810-257-0713
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704145655163WP0807X, 163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult