Provider Demographics
NPI:1629456785
Name:ROBERTS, GWENDOLYN
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:ROBERTS
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 1:2148 COUNTY ROAD 15
Mailing Address - Street 2:
Mailing Address - City:RAYLAND
Mailing Address - State:OH
Mailing Address - Zip Code:43943-7917
Mailing Address - Country:US
Mailing Address - Phone:740-733-7209
Mailing Address - Fax:
Practice Address - Street 1:2148 COUNTY ROAD 15
Practice Address - Street 2:
Practice Address - City:RAYLAND
Practice Address - State:OH
Practice Address - Zip Code:43943-7917
Practice Address - Country:US
Practice Address - Phone:740-733-7209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-11
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH102768094999Medicaid