Provider Demographics
NPI:1851165021
Name:STAFFORD, GWEN MADELINE
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:MADELINE
Last Name:STAFFORD
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 1:1707 N CREAM HILL RD
Mailing Address - Street 2:
Mailing Address - City:SHOREHAM
Mailing Address - State:VT
Mailing Address - Zip Code:05770-9707
Mailing Address - Country:US
Mailing Address - Phone:802-349-9832
Mailing Address - Fax:
Practice Address - Street 1:1707 N CREAM HILL RD
Practice Address - Street 2:
Practice Address - City:SHOREHAM
Practice Address - State:VT
Practice Address - Zip Code:05770-9707
Practice Address - Country:US
Practice Address - Phone:802-349-9832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-08
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer