Provider Demographics
NPI:1750150470
Name:STRUM, GWEN ELLEN (BSN, RN, IBCLC)
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:ELLEN
Last Name:STRUM
Suffix:
Gender:F
Credentials:BSN, RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 N DIXON AVE
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-1120
Mailing Address - Country:US
Mailing Address - Phone:815-285-5834
Mailing Address - Fax:
Practice Address - Street 1:215 E 1ST ST STE 215
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-3166
Practice Address - Country:US
Practice Address - Phone:815-285-5834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-21
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041393780163W00000X, 163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163W00000XNursing Service ProvidersRegistered Nurse