Provider Demographics
NPI:1154913119
Name:GATTISON, GWENDOLYN JETT
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:JETT
Last Name:GATTISON
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 1:1625 GREENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:DARLINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29540-9158
Mailing Address - Country:US
Mailing Address - Phone:843-307-1995
Mailing Address - Fax:
Practice Address - Street 1:1625 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:DARLINGTON
Practice Address - State:SC
Practice Address - Zip Code:29540-9158
Practice Address - Country:US
Practice Address - Phone:843-307-1995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker