Provider Demographics
NPI:1497306112
Name:GILEAD MEDICAL AND WELLNESS CLINIC, PLLC
Entity Type:Organization
Organization Name:GILEAD MEDICAL AND WELLNESS CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEYNADOMNICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:UDENZE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:214-727-8681
Mailing Address - Street 1:500 BENSON RD STE 115
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-3947
Mailing Address - Country:US
Mailing Address - Phone:214-727-8681
Mailing Address - Fax:984-246-2005
Practice Address - Street 1:500 BENSON RD STE 115
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-3947
Practice Address - Country:US
Practice Address - Phone:214-727-8681
Practice Address - Fax:984-246-2005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-24
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty