Provider Demographics
NPI:1497274096
Name:WOLFORD, GWEN GARIBALDI (FNP)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:GARIBALDI
Last Name:WOLFORD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 BROOKES XING
Mailing Address - Street 2:
Mailing Address - City:PONTOTOC
Mailing Address - State:MS
Mailing Address - Zip Code:38863-1009
Mailing Address - Country:US
Mailing Address - Phone:662-489-4044
Mailing Address - Fax:
Practice Address - Street 1:12 BROOKES XING
Practice Address - Street 2:
Practice Address - City:PONTOTOC
Practice Address - State:MS
Practice Address - Zip Code:38863-1009
Practice Address - Country:US
Practice Address - Phone:662-489-4044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-14
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902381363L00000X
TNAPN23055363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner