Provider Demographics
NPI:1720461817
Name:GWALTNEY, MANDY L
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:L
Last Name:GWALTNEY
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 1:7540W BROWN RD
Mailing Address - Street 2:
Mailing Address - City:MANISTIQUE
Mailing Address - State:MI
Mailing Address - Zip Code:49854-9555
Mailing Address - Country:US
Mailing Address - Phone:906-341-5975
Mailing Address - Fax:
Practice Address - Street 1:7540W BROWN RD
Practice Address - Street 2:
Practice Address - City:MANISTIQUE
Practice Address - State:MI
Practice Address - Zip Code:49854-9555
Practice Address - Country:US
Practice Address - Phone:906-341-5975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider