Provider Demographics
NPI:1902366800
Name:GWYNN, THOMAS NIELSEN (HIS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:NIELSEN
Last Name:GWYNN
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 SW 27TH PL
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-7802
Mailing Address - Country:US
Mailing Address - Phone:352-789-2742
Mailing Address - Fax:
Practice Address - Street 1:843 W STUART DR
Practice Address - Street 2:
Practice Address - City:HILLSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24343-1577
Practice Address - Country:US
Practice Address - Phone:276-728-9323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2101002440237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist