1558955385 NPI number — GWENDOLYN MARIE SHELBY ROUNTREE

Table of content: GWENDOLYN MARIE SHELBY ROUNTREE (NPI 1558955385)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558955385 NPI number — GWENDOLYN MARIE SHELBY ROUNTREE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROUNTREE
Provider First Name:
GWENDOLYN
Provider Middle Name:
MARIE SHELBY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JUSTUS
Provider Other First Name:
GWENDOLYN
Provider Other Middle Name:
MARIE SHELBY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1558955385
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/18/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 935921
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31193-5921
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 ADVENTHEALTH WAY STE 250
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM COAST
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32137-4702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-232-9487
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/23/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA9117513 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)