Provider Demographics
NPI:1255824959
Name:BANES, GWENDOLYN (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:BANES
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11354 VIA RANCHO SAN DIEGO UNIT D
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92019-5203
Mailing Address - Country:US
Mailing Address - Phone:619-309-9598
Mailing Address - Fax:
Practice Address - Street 1:995 GATEWAY CENTER WAY STE 300
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-4550
Practice Address - Country:US
Practice Address - Phone:619-398-2156
Practice Address - Fax:619-398-2168
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN655020163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA2634637OtherDRIVER LICENSE