Provider Demographics
NPI:1669848156
Name:GAMMON, WENDY WYNETTE (FNP)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:WYNETTE
Last Name:GAMMON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 295
Mailing Address - Street 2:
Mailing Address - City:LOCKESBURG
Mailing Address - State:AR
Mailing Address - Zip Code:71846-0295
Mailing Address - Country:US
Mailing Address - Phone:870-289-5865
Mailing Address - Fax:870-289-4594
Practice Address - Street 1:1305 ARKANSAS BLVD STE 104
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-1691
Practice Address - Country:US
Practice Address - Phone:870-648-1305
Practice Address - Fax:870-648-1306
Is Sole Proprietor?:No
Enumeration Date:2015-08-19
Last Update Date:2021-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005928363LF0000X
TXAP128853363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR225050758Medicaid