Provider Demographics
NPI:1568914166
Name:ROSS-WILLIAMS, GWENDOLYN J (NP)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:J
Last Name:ROSS-WILLIAMS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:GWENDOLYN
Other - Middle Name:J
Other - Last Name:ROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:4219 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-3822
Mailing Address - Country:US
Mailing Address - Phone:310-729-6489
Mailing Address - Fax:
Practice Address - Street 1:4219 WALNUT AVE
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-3822
Practice Address - Country:US
Practice Address - Phone:310-729-6489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-29
Last Update Date:2016-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3750363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner