Provider Demographics
NPI:1932282316
Name:WHITE, GWENDOLYN YVONNE (CRNA,MS)
Entity Type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:YVONNE
Last Name:WHITE
Suffix:
Gender:F
Credentials:CRNA,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24310 CUSTIS ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2504
Mailing Address - Country:US
Mailing Address - Phone:248-559-4508
Mailing Address - Fax:248-559-4508
Practice Address - Street 1:19401 HUBBARD DR
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2641
Practice Address - Country:US
Practice Address - Phone:313-982-8280
Practice Address - Fax:313-982-8271
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704105527367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered