Provider Demographics
NPI:1578828794
Name:STEPHENS, GWEN ELIZABETH (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:GWEN
Middle Name:ELIZABETH
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2039 KIMBERWICKE CIR
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-7577
Mailing Address - Country:US
Mailing Address - Phone:407-865-2833
Mailing Address - Fax:
Practice Address - Street 1:2039 KIMBERWICKE CIR
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-7577
Practice Address - Country:US
Practice Address - Phone:407-865-2833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-13
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1469912367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered