Provider Demographics
NPI:1659339372
Name:HOOPER, GWENDOLYN LUNELL (APRN)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:LUNELL
Last Name:HOOPER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:GWENDOLYN
Other - Middle Name:L
Other - Last Name:MOFFETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:PO BOX 24222
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40524-4222
Mailing Address - Country:US
Mailing Address - Phone:859-271-3581
Mailing Address - Fax:
Practice Address - Street 1:1780 MCFARLAND BLVD N
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35406-2136
Practice Address - Country:US
Practice Address - Phone:205-345-7351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3054P363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78014560Medicaid
KY78014560Medicaid
0621254Medicare ID - Type Unspecified