Provider Demographics
NPI:1275324295
Name:GORDILLO, WYNETTE E
Entity type:Individual
Prefix:
First Name:WYNETTE
Middle Name:E
Last Name:GORDILLO
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 1:5505 N MCKAY AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-1209
Mailing Address - Country:US
Mailing Address - Phone:813-573-7974
Mailing Address - Fax:
Practice Address - Street 1:5505 N MCKAY AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-1209
Practice Address - Country:US
Practice Address - Phone:813-573-7974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-16
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3000935347C00000X, 343900000X, 344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi
No347C00000XTransportation ServicesPrivate Vehicle
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)