Provider Demographics
NPI:1346432648
Name:NOACK, GWENDOLYNNE ELIZABETH (LMT)
Entity type:Individual
Prefix:
First Name:GWENDOLYNNE
Middle Name:ELIZABETH
Last Name:NOACK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 321521
Mailing Address - Street 2:
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32932-1521
Mailing Address - Country:US
Mailing Address - Phone:321-258-5842
Mailing Address - Fax:
Practice Address - Street 1:6615 N ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:CAPE CANAVERAL
Practice Address - State:FL
Practice Address - Zip Code:32920-5814
Practice Address - Country:US
Practice Address - Phone:321-258-5842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-10
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 34525174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist