Provider Demographics
NPI:1538474473
Name:WILSON, GWENDOLYN
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93302-1559
Mailing Address - Country:US
Mailing Address - Phone:661-397-8775
Mailing Address - Fax:661-397-8286
Practice Address - Street 1:1400 S UNION AVE STE 100
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93307-4179
Practice Address - Country:US
Practice Address - Phone:661-397-8775
Practice Address - Fax:661-397-8286
Is Sole Proprietor?:No
Enumeration Date:2010-08-16
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator