Provider Demographics
NPI:1255897997
Name:LEE, GWENDOLYN NA
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:NA
Last Name:LEE
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 1:2200 BELVOIR BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44121-1204
Mailing Address - Country:US
Mailing Address - Phone:216-400-1121
Mailing Address - Fax:
Practice Address - Street 1:2200 BELVOIR BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44121-1204
Practice Address - Country:US
Practice Address - Phone:216-400-1121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide