1861530883 NPI number — GWENDOLYN DIANNE LEE CNM

Table of content: GWENDOLYN DIANNE LEE CNM (NPI 1861530883)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861530883 NPI number — GWENDOLYN DIANNE LEE CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEE
Provider First Name:
GWENDOLYN
Provider Middle Name:
DIANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861530883
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/24/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3001 HOSPITAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHEVERLY
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20785-1189
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-618-2355
Provider Business Mailing Address Fax Number:
301-618-3521

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
901 HARRY S TRUMAN DRIVE NORTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LARGO
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20774
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-677-2000
Provider Business Practice Location Address Fax Number:
240-677-0066
Provider Enumeration Date:
02/02/2007

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: 367A00000X , with the licence number:  R052268 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 402527000 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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