Provider Demographics
NPI:1326194853
Name:JELLISH, GWEN ANNETTE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:GWEN
Middle Name:ANNETTE
Last Name:JELLISH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N8160 BIG LAKE LN
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:54169-9666
Mailing Address - Country:US
Mailing Address - Phone:920-475-4489
Mailing Address - Fax:
Practice Address - Street 1:N8160 BIG LAKE LN
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:WI
Practice Address - Zip Code:54169-9666
Practice Address - Country:US
Practice Address - Phone:920-475-4489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6880-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse