Provider Demographics
NPI:1427516749
Name:IGLESIAS, GWENDOLYN
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:IGLESIAS
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 1:4518 ETHAN WAY
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33563-8541
Mailing Address - Country:US
Mailing Address - Phone:863-409-0755
Mailing Address - Fax:
Practice Address - Street 1:4518 ETHAN WAY
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-8541
Practice Address - Country:US
Practice Address - Phone:863-409-0755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker