Provider Demographics
NPI:1184043796
Name:MURPHY, GWENDOLYN (ATC)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:MURPHY
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 1/2 LYON PL
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-6106
Mailing Address - Country:US
Mailing Address - Phone:315-520-4059
Mailing Address - Fax:
Practice Address - Street 1:12 1/2 LYON PL
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-6106
Practice Address - Country:US
Practice Address - Phone:315-520-4059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-10
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0052022255A2300X
NY67 0029712255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer