Provider Demographics
NPI:1588621130
Name:BAKER, GWENDOLYN ANN (LPN)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:ANN
Last Name:BAKER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3981 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SHADYSIDE
Mailing Address - State:OH
Mailing Address - Zip Code:43947-1256
Mailing Address - Country:US
Mailing Address - Phone:740-676-2002
Mailing Address - Fax:
Practice Address - Street 1:62440 CUMBERLAND RUN RD
Practice Address - Street 2:
Practice Address - City:JACOBSBURG
Practice Address - State:OH
Practice Address - Zip Code:43933-9717
Practice Address - Country:US
Practice Address - Phone:740-686-2199
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN064334164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2175266Medicaid