Provider Demographics
NPI:1053786459
Name:SMITH, GWYNDOLEN (LPN)
Entity type:Individual
Prefix:MS
First Name:GWYNDOLEN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15620 N 55TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-3038
Mailing Address - Country:US
Mailing Address - Phone:602-314-6036
Mailing Address - Fax:
Practice Address - Street 1:711 E MISSOURI AVE STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2811
Practice Address - Country:US
Practice Address - Phone:602-433-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP042073164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse