Provider Demographics
NPI:1104093723
Name:CHEW, GWENEVERE (CFNP)
Entity type:Individual
Prefix:
First Name:GWENEVERE
Middle Name:
Last Name:CHEW
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 SECURITY SQ
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-1932
Mailing Address - Country:US
Mailing Address - Phone:662-741-2151
Mailing Address - Fax:662-741-2700
Practice Address - Street 1:340 DESOTO AVENUE EXT
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-2814
Practice Address - Country:US
Practice Address - Phone:662-741-2151
Practice Address - Fax:662-741-2700
Is Sole Proprietor?:No
Enumeration Date:2008-05-13
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR637211363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP01623Medicare Oscar/Certification