Provider Demographics
NPI:1932343308
Name:PRYOR, GWENDOLYN MICHELLE (NP)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:MICHELLE
Last Name:PRYOR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4341 BRISTOLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-3743
Mailing Address - Country:US
Mailing Address - Phone:810-762-5913
Mailing Address - Fax:
Practice Address - Street 1:221 S MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-2653
Practice Address - Country:US
Practice Address - Phone:248-398-6459
Practice Address - Fax:248-398-6265
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-28
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN4704235826363LA2200X
MI4704235826363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health