Provider Demographics
NPI:1255853420
Name:MANIGAULT, GWENDOLYN O
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:O
Last Name:MANIGAULT
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 1:4320 SHELDON AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPLE HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20748-1836
Mailing Address - Country:US
Mailing Address - Phone:301-674-8757
Mailing Address - Fax:
Practice Address - Street 1:4320 SHELDON AVE
Practice Address - Street 2:
Practice Address - City:TEMPLE HILLS
Practice Address - State:MD
Practice Address - Zip Code:20748-1836
Practice Address - Country:US
Practice Address - Phone:301-674-8757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant