Provider Demographics
NPI:1720838758
Name:HEDLUND, GWEN (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:HEDLUND
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6312 N MANLIUS RD
Mailing Address - Street 2:
Mailing Address - City:KIRKVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13082-9323
Mailing Address - Country:US
Mailing Address - Phone:315-664-5301
Mailing Address - Fax:
Practice Address - Street 1:168 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13204-4116
Practice Address - Country:US
Practice Address - Phone:315-218-6492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY566684163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)