Provider Demographics
NPI:1649040114
Name:CUPP, GWEN
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:CUPP
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 1:420 E LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:LEIPSIC
Mailing Address - State:OH
Mailing Address - Zip Code:45856-1420
Mailing Address - Country:US
Mailing Address - Phone:419-957-2434
Mailing Address - Fax:
Practice Address - Street 1:420 E LIBERTY ST
Practice Address - Street 2:
Practice Address - City:LEIPSIC
Practice Address - State:OH
Practice Address - Zip Code:45856-1420
Practice Address - Country:US
Practice Address - Phone:419-957-2434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-05
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care