Provider Demographics
NPI:1578253878
Name:KELLEHER, GWYNETH
Entity Type:Individual
Prefix:
First Name:GWYNETH
Middle Name:
Last Name:KELLEHER
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 1:16 SOUTH ST APT 2
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-4258
Mailing Address - Country:US
Mailing Address - Phone:704-451-2737
Mailing Address - Fax:
Practice Address - Street 1:16 SOUTH ST APT 2
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-4258
Practice Address - Country:US
Practice Address - Phone:704-451-2737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program