Provider Demographics
NPI:1578973111
Name:FROST, GWEN
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:FROST
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 1:6022 JEFFERSON AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23605-3000
Mailing Address - Country:US
Mailing Address - Phone:757-244-0511
Mailing Address - Fax:757-320-2900
Practice Address - Street 1:6022 JEFFERSON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23605-3000
Practice Address - Country:US
Practice Address - Phone:757-244-0511
Practice Address - Fax:757-320-2900
Is Sole Proprietor?:No
Enumeration Date:2014-05-05
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0153730830Medicaid
VA0513662736Medicaid