Provider Demographics
NPI:1750609434
Name:WATSON, GWENDOLYN JEAN
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:JEAN
Last Name:WATSON
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 1:3308 PARKER DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73135-1438
Mailing Address - Country:US
Mailing Address - Phone:405-670-3001
Mailing Address - Fax:
Practice Address - Street 1:3824 N MERIDIAN AVE STE 104
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2805
Practice Address - Country:US
Practice Address - Phone:405-602-0835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-05
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator