Provider Demographics
NPI:1821133125
Name:BLAYDE, GWENDOLYN E (RN)
Entity Type:Individual
Prefix:MS
First Name:GWENDOLYN
Middle Name:E
Last Name:BLAYDE
Suffix:
Gender:F
Credentials:RN
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 188
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38068-0188
Mailing Address - Country:US
Mailing Address - Phone:901-465-5243
Mailing Address - Fax:901-465-5245
Practice Address - Street 1:90 YUM YUM RD
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38068-4541
Practice Address - Country:US
Practice Address - Phone:901-435-5243
Practice Address - Fax:901-465-5245
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN77274163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse