Provider Demographics
NPI:1427898493
Name:MASTENBROOK, GWEN ALANI
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:ALANI
Last Name:MASTENBROOK
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 1:8728 PLEASANT LAKE DR
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-9110
Mailing Address - Country:US
Mailing Address - Phone:810-923-2623
Mailing Address - Fax:
Practice Address - Street 1:2280 E GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-8503
Practice Address - Country:US
Practice Address - Phone:517-546-4126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-28
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker