Provider Demographics
NPI:1255929782
Name:LOVE, GWENDILYN SUZANNE
Entity type:Individual
Prefix:
First Name:GWENDILYN
Middle Name:SUZANNE
Last Name:LOVE
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 1:4500 19TH ST LOT 398
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-0664
Mailing Address - Country:US
Mailing Address - Phone:720-329-3494
Mailing Address - Fax:
Practice Address - Street 1:4500 19TH ST LOT 398
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-0664
Practice Address - Country:US
Practice Address - Phone:720-329-3494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-10
Last Update Date:2021-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPN.0046746164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse