Provider Demographics
NPI:1336594894
Name:STEVENS, GWENLOU ARLISE (HEALTH TECHNICIAN)
Entity Type:Individual
Prefix:
First Name:GWENLOU
Middle Name:ARLISE
Last Name:STEVENS
Suffix:
Gender:F
Credentials:HEALTH TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 MERCANTILE LN STE 100L
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-5390
Mailing Address - Country:US
Mailing Address - Phone:301-404-3532
Mailing Address - Fax:301-043-5324
Practice Address - Street 1:1300 MERCANTILE LN STE 100L
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-5390
Practice Address - Country:US
Practice Address - Phone:301-404-3532
Practice Address - Fax:301-404-3532
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-03
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247000000X
FL247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Yes247000000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health Information