Provider Demographics
NPI:1356541643
Name:WARD, GANNON J (CNM)
Entity type:Individual
Prefix:MRS
First Name:GANNON
Middle Name:J
Last Name:WARD
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
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Mailing Address - Street 1:345 WHITNEY AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-2348
Mailing Address - Country:US
Mailing Address - Phone:203-752-2856
Mailing Address - Fax:203-752-8785
Practice Address - Street 1:1039 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-4108
Practice Address - Country:US
Practice Address - Phone:203-327-2722
Practice Address - Fax:203-975-4539
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2012-04-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC193956367A00000X
CT00350367A00000X
CT350367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCMW0171Medicaid
NC7002120Medicaid
NC2592332AMedicare PIN