Provider Demographics
NPI:1972774578
Name:ECKLES, GWENDOLYN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:
Last Name:ECKLES
Suffix:
Gender:F
Credentials:LPN
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 296
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:NY
Mailing Address - Zip Code:14047-0296
Mailing Address - Country:US
Mailing Address - Phone:716-562-7012
Mailing Address - Fax:716-562-7109
Practice Address - Street 1:7008 ERIE RD
Practice Address - Street 2:SUITE 14
Practice Address - City:DERBY
Practice Address - State:NY
Practice Address - Zip Code:14047-9592
Practice Address - Country:US
Practice Address - Phone:716-562-7012
Practice Address - Fax:716-562-7109
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-21
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10-265253164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse