Provider Demographics
NPI:1649564121
Name:MATTOX, GWEN D (LVN)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:D
Last Name:MATTOX
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 2087
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95341-6217
Mailing Address - Country:US
Mailing Address - Phone:209-381-6819
Mailing Address - Fax:209-381-6871
Practice Address - Street 1:300 E 15TH ST
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95341-6217
Practice Address - Country:US
Practice Address - Phone:209-381-6819
Practice Address - Fax:209-381-6871
Is Sole Proprietor?:No
Enumeration Date:2011-06-02
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA236591164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse