Provider Demographics
NPI:1629226808
Name:LATENDRESSE, GWEN (CNM, PHD)
Entity Type:Individual
Prefix:DR
First Name:GWEN
Middle Name:
Last Name:LATENDRESSE
Suffix:
Gender:F
Credentials:CNM, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 S 2000 E
Mailing Address - Street 2:ROOM 448
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84112-5880
Mailing Address - Country:US
Mailing Address - Phone:801-587-9636
Mailing Address - Fax:801-587-9838
Practice Address - Street 1:10 S 2000 E
Practice Address - Street 2:ROOM 448
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-5880
Practice Address - Country:US
Practice Address - Phone:801-587-9636
Practice Address - Fax:801-587-9838
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-30
Last Update Date:2008-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT95-216631-4402367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife