Provider Demographics
NPI:1336984186
Name:WATERS, GWENDOLYN (CNA)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:WATERS
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 36TH AVE NE APT 210
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58703-0586
Mailing Address - Country:US
Mailing Address - Phone:813-713-1517
Mailing Address - Fax:
Practice Address - Street 1:500 36TH AVE NE APT 210
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58703-0586
Practice Address - Country:US
Practice Address - Phone:813-713-1517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant