Provider Demographics
NPI:1316084643
Name:VANDOOREN, GWENDOLYN ANN (DC)
Entity type:Individual
Prefix:DR
First Name:GWENDOLYN
Middle Name:ANN
Last Name:VANDOOREN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:GWENDOLYN
Other - Middle Name:ANN
Other - Last Name:THOMPSON VANDOOREN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:17 BUTTERCUP RD
Mailing Address - Street 2:
Mailing Address - City:HAILEY
Mailing Address - State:ID
Mailing Address - Zip Code:83333-5097
Mailing Address - Country:US
Mailing Address - Phone:208-788-1863
Mailing Address - Fax:
Practice Address - Street 1:17 BUTTERCUP RD
Practice Address - Street 2:
Practice Address - City:HAILEY
Practice Address - State:ID
Practice Address - Zip Code:83333-5097
Practice Address - Country:US
Practice Address - Phone:208-788-1863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA866111N00000X
WACH00002501111N00000X
OR282720111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC8661OtherBLUE CROSS OF IDAHO
ID000010028728OtherREGENCE BLUE SHIELD OF ID