Provider Demographics
NPI:1376192435
Name:SMITH, GWENDOLYN D
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:D
Last Name:SMITH
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 1:10526 PACE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90002-3425
Mailing Address - Country:US
Mailing Address - Phone:213-915-1100
Mailing Address - Fax:
Practice Address - Street 1:10526 PACE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90002-3425
Practice Address - Country:US
Practice Address - Phone:213-915-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health