Provider Demographics
NPI:1558955385
Name:ROUNTREE, GWENDOLYN MARIE SHELBY
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:MARIE SHELBY
Last Name:ROUNTREE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:GWENDOLYN
Other - Middle Name:MARIE SHELBY
Other - Last Name:JUSTUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 935921
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-5921
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3 ADVENTHEALTH WAY STE 250
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-4702
Practice Address - Country:US
Practice Address - Phone:386-232-9487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-23
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9117513363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant