Provider Demographics
NPI:1285649749
Name:SHELTON, GWENDOLYN (MD)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:SHELTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GWENDOLYN
Other - Middle Name:S
Other - Last Name:LATTIMORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1116 MILLIS AVE
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47601-2204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1116 MILLIS AVE
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47601-2204
Practice Address - Country:US
Practice Address - Phone:812-897-7404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2002-0294208000000X
VT0420012043208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM41835557Medicaid
VT1018027Medicaid
VT1018027Medicaid
NM41835557Medicaid
342707803Medicare PIN