Provider Demographics
NPI:1700320173
Name:DAVIS, GWENDOLYN
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:DAVIS
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 1:626 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:AR
Mailing Address - Zip Code:72342-3140
Mailing Address - Country:US
Mailing Address - Phone:870-338-8163
Mailing Address - Fax:870-338-7810
Practice Address - Street 1:626 POPLAR ST
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:AR
Practice Address - Zip Code:72342-3140
Practice Address - Country:US
Practice Address - Phone:870-338-8163
Practice Address - Fax:870-338-7810
Is Sole Proprietor?:No
Enumeration Date:2016-12-05
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004882363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily