Provider Demographics
NPI:1558958454
Name:BODEN, GWENDOLYN (RN)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:BODEN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2506 CLAM BED CT
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-6600
Mailing Address - Country:US
Mailing Address - Phone:802-922-2955
Mailing Address - Fax:
Practice Address - Street 1:2506 CLAM BED CT
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-6600
Practice Address - Country:US
Practice Address - Phone:802-922-2955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-25
Last Update Date:2020-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH072569-21163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse