Provider Demographics
NPI:1407567639
Name:SANTANA, GWENDOLYN (DOULA)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:SANTANA
Suffix:
Gender:F
Credentials:DOULA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2423 MOUNTAIN VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-2134
Mailing Address - Country:US
Mailing Address - Phone:917-674-3072
Mailing Address - Fax:
Practice Address - Street 1:2423 MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-2134
Practice Address - Country:US
Practice Address - Phone:917-674-3072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-08
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF6A856B334374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLL21000093686Medicaid