Provider Demographics
NPI:1558955385
Name:ROUNTREE, GWENDOLYN MARIE SHELBY
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:MARIE SHELBY
Last Name:ROUNTREE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GWENDOLYN
Other - Middle Name:MARIE SHELBY
Other - Last Name:JUSTUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:400 HEALTH PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5784
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:904-819-4906
Practice Address - Street 1:120 HEALTH PARK BLVD STE 1
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5798
Practice Address - Country:US
Practice Address - Phone:888-481-2135
Practice Address - Fax:386-627-7319
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-23
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLPA9117513363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program