Provider Demographics
NPI:1992779854
Name:GANT, GWENDOLYNNE P (PT)
Entity type:Individual
Prefix:MRS
First Name:GWENDOLYNNE
Middle Name:P
Last Name:GANT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:GWYNN
Other - Middle Name:P
Other - Last Name:GANT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:403 N MILES ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-1834
Mailing Address - Country:US
Mailing Address - Phone:270-360-9129
Mailing Address - Fax:270-234-8197
Practice Address - Street 1:115 S SALEM DR
Practice Address - Street 2:PHYSICAL THERAPY ASSOCIATES
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-1762
Practice Address - Country:US
Practice Address - Phone:502-350-0880
Practice Address - Fax:502-350-3640
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1760225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000192994OtherANTHEM
KY8700031100Medicaid
CJ8198OtherRAILROAD MEDICARE PIN
00907OtherFACILITY MEDICARE PIN
P28886Medicare UPIN
KY5025401Medicare PIN