Provider Demographics
NPI:1356875520
Name:GWINN, GRACE (MS, ATC)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:GWINN
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 WOODFIELD DR
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WV
Mailing Address - Zip Code:25541-1055
Mailing Address - Country:US
Mailing Address - Phone:304-633-5853
Mailing Address - Fax:
Practice Address - Street 1:1500 BLAZER BLVD
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41102-5606
Practice Address - Country:US
Practice Address - Phone:304-633-5853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-14
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer