Provider Demographics
NPI:1093549032
Name:BARBER, GWENDOLYN MICHELE
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:MICHELE
Last Name:BARBER
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:PO BOX 21011
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55421-0011
Mailing Address - Country:US
Mailing Address - Phone:612-407-0776
Mailing Address - Fax:
Practice Address - Street 1:501 DALE ST N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55103-1914
Practice Address - Country:US
Practice Address - Phone:612-407-0776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-30
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN175T00000X
251E00000X, 374U00000X
MNNA405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional
No175T00000XOther Service ProvidersPeer Specialist
No251E00000XAgenciesHome Health
No374U00000XNursing Service Related ProvidersHome Health Aide