Provider Demographics
NPI:1184081937
Name:CUNNINGHAM, GWENDOLYN LALISA
Entity type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:LALISA
Last Name:CUNNINGHAM
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 1:8020 MONCRIEF DINSMORE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32219-3602
Mailing Address - Country:US
Mailing Address - Phone:904-627-6031
Mailing Address - Fax:
Practice Address - Street 1:3741 JACOB LOIS DR W
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-2972
Practice Address - Country:US
Practice Address - Phone:904-627-6031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator