Provider Demographics
NPI:1104864602
Name:GUEGOLD, GWEN A (FNP)
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:A
Last Name:GUEGOLD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6350 W ANDREW JOHNSON HWY
Mailing Address - Street 2:DEPARTMENT 100
Mailing Address - City:TALBOTT
Mailing Address - State:TN
Mailing Address - Zip Code:37877-8605
Mailing Address - Country:US
Mailing Address - Phone:800-355-3565
Mailing Address - Fax:423-714-2355
Practice Address - Street 1:3360 HIGHWAY 411 N
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:TN
Practice Address - Zip Code:37329-5276
Practice Address - Country:US
Practice Address - Phone:423-887-5131
Practice Address - Fax:423-887-5917
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5518363L00000X
TNAPN5518363LF0000X
TNRN49800163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3072348OtherBLUE CROSS BLUE SHIELD #
TN3344283Medicaid
TNS43538Medicare UPIN
TN3344283Medicaid