Provider Demographics
NPI:1659973451
Name:WILBOURNE, GAVAUGHNA
Entity Type:Individual
Prefix:
First Name:GAVAUGHNA
Middle Name:
Last Name:WILBOURNE
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 1:1300 RENAISSANCE CIR APT 404
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25311-1545
Mailing Address - Country:US
Mailing Address - Phone:681-945-3567
Mailing Address - Fax:
Practice Address - Street 1:1300 RENAISSANCE CIR APT 404
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25311-1545
Practice Address - Country:US
Practice Address - Phone:681-945-3567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant