Provider Demographics
NPI:1437931078
Name:GANNON, GWENDOLYN (RN-BC, CRRN, CCM)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:GANNON
Suffix:
Gender:F
Credentials:RN-BC, CRRN, CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 WILSON RUN RD
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:KY
Mailing Address - Zip Code:41093-8955
Mailing Address - Country:US
Mailing Address - Phone:843-813-4410
Mailing Address - Fax:
Practice Address - Street 1:16030 CARNATION DR
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33955-7156
Practice Address - Country:US
Practice Address - Phone:843-813-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
FL2833022163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No171M00000XOther Service ProvidersCase Manager/Care Coordinator