Provider Demographics
NPI:1841454196
Name:MOBLEY, GWENDOLYN DENESE
Entity type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:DENESE
Last Name:MOBLEY
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:PO BOX 1378
Mailing Address - Street 2:
Mailing Address - City:BUSHNELL
Mailing Address - State:FL
Mailing Address - Zip Code:33513-0077
Mailing Address - Country:US
Mailing Address - Phone:352-793-2013
Mailing Address - Fax:
Practice Address - Street 1:6561 CR 476A
Practice Address - Street 2:
Practice Address - City:BUSHNELL
Practice Address - State:FL
Practice Address - Zip Code:33513-4823
Practice Address - Country:US
Practice Address - Phone:352-793-2013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-16
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6926410 98171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator