Provider Demographics
NPI:1932836756
Name:DEW, GWEN (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:DEW
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:ANGUILLA
Mailing Address - State:MS
Mailing Address - Zip Code:38721-9428
Mailing Address - Country:US
Mailing Address - Phone:662-907-0802
Mailing Address - Fax:
Practice Address - Street 1:1855 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4913
Practice Address - Country:US
Practice Address - Phone:601-366-4696
Practice Address - Fax:855-708-3030
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS905482363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health