Provider Demographics
NPI:1942242664
Name:STUP, GWYNN (APR,N)
Entity Type:Individual
Prefix:
First Name:GWYNN
Middle Name:
Last Name:STUP
Suffix:
Gender:F
Credentials:APR,N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1326 S GOVERNORS AVE
Mailing Address - Street 2:STE C
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-4800
Mailing Address - Country:US
Mailing Address - Phone:302-222-8304
Mailing Address - Fax:302-736-1280
Practice Address - Street 1:1326 S GOVERNORS AVE
Practice Address - Street 2:STE C
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-4800
Practice Address - Country:US
Practice Address - Phone:302-222-8304
Practice Address - Fax:302-736-1280
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2017-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DELE-0000166364SP0808X, 364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000036563Medicaid
017440B99Medicare ID - Type Unspecified