Provider Demographics
NPI:1376254003
Name:GREATHEART, GWENDOLYN
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:GREATHEART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TWISTED
Other - Middle Name:
Other - Last Name:DIAMONDS ENTERPRISE LLC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:912 PINELAND AVE APT 50
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-6058
Mailing Address - Country:US
Mailing Address - Phone:404-740-5249
Mailing Address - Fax:
Practice Address - Street 1:912 PINELAND AVE APT 50
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-6058
Practice Address - Country:US
Practice Address - Phone:404-740-5249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-13
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA025727133343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)