Provider Demographics
NPI:1104330588
Name:DEMAREST, GWEN MARIE
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:MARIE
Last Name:DEMAREST
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 1:2008 N CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98406-6636
Mailing Address - Country:US
Mailing Address - Phone:253-495-1915
Mailing Address - Fax:
Practice Address - Street 1:26630 40TH AVE S
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-7017
Practice Address - Country:US
Practice Address - Phone:253-945-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-21
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP60452384164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse