Provider Demographics
NPI:1497455612
Name:COXUM, GWENDOLYN CHRISTANNE
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:CHRISTANNE
Last Name:COXUM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 TILGHMAN DR APT 5B
Mailing Address - Street 2:
Mailing Address - City:DUNN
Mailing Address - State:NC
Mailing Address - Zip Code:28334-5528
Mailing Address - Country:US
Mailing Address - Phone:919-464-0355
Mailing Address - Fax:
Practice Address - Street 1:1411 W CUMBERLAND ST
Practice Address - Street 2:
Practice Address - City:DUNN
Practice Address - State:NC
Practice Address - Zip Code:28334-4503
Practice Address - Country:US
Practice Address - Phone:919-464-0355
Practice Address - Fax:
Is Sole Proprietor?:
Enumeration Date:2023-03-07
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC23940174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist