Basic Information
| Provider Information | |||||||||
| NPI: | 1023374139 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WREN | ||||||||
| FirstName: | GWENDOLYN | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CACDP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2459 PARKER ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482141824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137432540 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13336 E WARREN AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482152112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138226940 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2012 | ||||||||
| LastUpdateDate: | 04/03/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133NN1002X | N | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education | 133NN1002X | 133N1002X | MI | Y | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education |
No ID Information.