Provider Demographics
NPI:1235401563
Name:WILBUR, GWENAN (RN, IBCLC)
Entity Type:Individual
Prefix:MS
First Name:GWENAN
Middle Name:
Last Name:WILBUR
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6647 N TALMAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-5008
Mailing Address - Country:US
Mailing Address - Phone:773-465-2766
Mailing Address - Fax:
Practice Address - Street 1:6647 N TALMAN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-5008
Practice Address - Country:US
Practice Address - Phone:773-465-2766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-01
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041332219163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant