Provider Demographics
NPI:1356040653
Name:WIDNER, GINA
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:WIDNER
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 1:10775 MCKINLEY HWY STE C
Mailing Address - Street 2:
Mailing Address - City:OSCEOLA
Mailing Address - State:IN
Mailing Address - Zip Code:46561-9164
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10775 MCKINLEY HWY STE C
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:IN
Practice Address - Zip Code:46561-9164
Practice Address - Country:US
Practice Address - Phone:574-213-2102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
L-308297OtherIBCLE