Provider Demographics
NPI:1215703715
Name:PELATE, GWENDOLYN C (CNA)
Entity type:Individual
Prefix:MS
First Name:GWENDOLYN
Middle Name:C
Last Name:PELATE
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:MS
Other - First Name:GWENDOLYN
Other - Middle Name:C
Other - Last Name:PREWITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:224 MYLAUN DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1740
Mailing Address - Country:US
Mailing Address - Phone:217-317-1790
Mailing Address - Fax:
Practice Address - Street 1:33 LAKEWOOD DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-3156
Practice Address - Country:US
Practice Address - Phone:217-317-1790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide