Provider Demographics
NPI:1710407960
Name:GILLENWATER, ALANA A (DPT)
Entity Type:Individual
Prefix:
First Name:ALANA
Middle Name:A
Last Name:GILLENWATER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3942 DAVIS STUART RD STE 3
Mailing Address - Street 2:
Mailing Address - City:RONCEVERTE
Mailing Address - State:WV
Mailing Address - Zip Code:24970-0269
Mailing Address - Country:US
Mailing Address - Phone:304-647-3987
Mailing Address - Fax:304-647-3990
Practice Address - Street 1:155 RESTON PL
Practice Address - Street 2:
Practice Address - City:GASSAWAY
Practice Address - State:WV
Practice Address - Zip Code:26624-9356
Practice Address - Country:US
Practice Address - Phone:304-364-9191
Practice Address - Fax:304-364-9193
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPT003799208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation