Provider Demographics
NPI:1952050882
Name:EVANS, GWENDOLYN LENORA W
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:LENORA W
Last Name:EVANS
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 1:1196 THIRD AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-3103
Mailing Address - Country:US
Mailing Address - Phone:619-427-4661
Mailing Address - Fax:619-426-7849
Practice Address - Street 1:1196 THIRD AVE FL 1
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-3103
Practice Address - Country:US
Practice Address - Phone:619-427-4661
Practice Address - Fax:619-426-7849
Is Sole Proprietor?:No
Enumeration Date:2022-03-19
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program