Provider Demographics
NPI:1356073522
Name:STEPHENS, GAWANDA RENEE
Entity Type:Individual
Prefix:
First Name:GAWANDA
Middle Name:RENEE
Last Name:STEPHENS
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 1:414 PINE BLUFF RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31705-2128
Mailing Address - Country:US
Mailing Address - Phone:229-733-5337
Mailing Address - Fax:
Practice Address - Street 1:1601 RADIUM SPRINGS RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31705-4093
Practice Address - Country:US
Practice Address - Phone:229-438-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker