Provider Demographics
NPI:1568459568
Name:PERRY-BRYE, GWENDOLYN M (RNC, MS, WHNP)
Entity type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:M
Last Name:PERRY-BRYE
Suffix:
Gender:F
Credentials:RNC, MS, WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3109 SOUTHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-5415
Mailing Address - Country:US
Mailing Address - Phone:262-554-8094
Mailing Address - Fax:
Practice Address - Street 1:8600 SHERIDAN RD STE 600
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-6515
Practice Address - Country:US
Practice Address - Phone:262-605-6700
Practice Address - Fax:262-605-6715
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI486-033363LW0102X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4385700Medicaid