Provider Demographics
NPI:1265184956
Name:CROMARTIE, GWENVANETTE
Entity type:Individual
Prefix:
First Name:GWENVANETTE
Middle Name:
Last Name:CROMARTIE
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 1:3730 NW 195TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33055-1938
Mailing Address - Country:US
Mailing Address - Phone:305-621-6324
Mailing Address - Fax:305-474-8566
Practice Address - Street 1:3730 NW 195TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33055-1938
Practice Address - Country:US
Practice Address - Phone:305-621-6324
Practice Address - Fax:305-474-0969
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-24
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11-88-GH251S00000X, 253Z00000X
FL11-431-GH253Z00000X
FL5113-5-GA253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL681582196Medicaid