Provider Demographics
NPI:1225800915
Name:BRODESS, GWENDOLYN HOPE
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:HOPE
Last Name:BRODESS
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 1:314 1/2 EAST THIRD ST.
Mailing Address - Street 2:
Mailing Address - City:PIKETON
Mailing Address - State:OH
Mailing Address - Zip Code:45661
Mailing Address - Country:US
Mailing Address - Phone:740-708-3480
Mailing Address - Fax:
Practice Address - Street 1:314 1/2 EAST THIRD ST
Practice Address - Street 2:
Practice Address - City:PIKETON
Practice Address - State:OH
Practice Address - Zip Code:45661
Practice Address - Country:US
Practice Address - Phone:740-708-3480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH00588593747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0058859Medicaid