Provider Demographics
NPI:1972591048
Name:BURTCH-WHITE, GWEN E (CNM)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:E
Last Name:BURTCH-WHITE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25317
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33622-5317
Mailing Address - Country:US
Mailing Address - Phone:813-286-0033
Mailing Address - Fax:813-282-1806
Practice Address - Street 1:2665 STATE ROAD 580
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-3166
Practice Address - Country:US
Practice Address - Phone:727-725-5121
Practice Address - Fax:727-725-5417
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1591792367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY3791ZMedicare ID - Type Unspecified
FLP26595Medicare UPIN