Provider Demographics
NPI:1962647651
Name:BROWN, GWENDOLYN MICHELLE (CNA)
Entity type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:MICHELLE
Last Name:BROWN
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:MISS
Other - First Name:GWENDOLYN
Other - Middle Name:MICHELLE
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNA
Mailing Address - Street 1:1114 1/2 VENABLE ST.
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648
Mailing Address - Country:US
Mailing Address - Phone:601-248-5267
Mailing Address - Fax:
Practice Address - Street 1:1114 1/2 VENABLE ST.
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648
Practice Address - Country:US
Practice Address - Phone:601-248-5267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-09
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSA023062374U00000X, 376J00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker