Provider Demographics
NPI:1962558726
Name:WILLMON, GWENDOLYN L (DC)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:L
Last Name:WILLMON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4119 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5334
Mailing Address - Country:US
Mailing Address - Phone:907-248-2848
Mailing Address - Fax:
Practice Address - Street 1:4119 LAUREL ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5334
Practice Address - Country:US
Practice Address - Phone:907-248-2848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR273155111N00000X
AK530111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor