Provider Demographics
NPI:1013976778
Name:WADE, GWEN E (RN)
Entity Type:Individual
Prefix:MRS
First Name:GWEN
Middle Name:E
Last Name:WADE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4169 N 62ND ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-1234
Mailing Address - Country:US
Mailing Address - Phone:414-438-4006
Mailing Address - Fax:
Practice Address - Street 1:4169 N 62ND ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-1234
Practice Address - Country:US
Practice Address - Phone:414-438-4006
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38291600OtherPROVIDER NUMBER