Provider Demographics
NPI:1588063416
Name:MAVIS, GWEN M (LPN)
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:M
Last Name:MAVIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14223 HIGHWAY U
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:MO
Mailing Address - Zip Code:64076-6467
Mailing Address - Country:US
Mailing Address - Phone:608-343-8808
Mailing Address - Fax:
Practice Address - Street 1:819 S BUS HWY 13
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MO
Practice Address - Zip Code:64067-1515
Practice Address - Country:US
Practice Address - Phone:660-259-3898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-15
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO16W00000X164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse