Basic Information
| Provider Information | |||||||||
| NPI: | 1164657474 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VILLELA | ||||||||
| FirstName: | GWENDOLYN | ||||||||
| MiddleName: | DENISE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CANNON | ||||||||
| OtherFirstName: | GWENDOLYN | ||||||||
| OtherMiddleName: | DENISE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 111 HARRILSON RD | ||||||||
| Address2: | |||||||||
| City: | CHERRYVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280219541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044354161 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 111 HARRILSON RD | ||||||||
| Address2: | |||||||||
| City: | CHERRYVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280219541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044354161 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2009 | ||||||||
| LastUpdateDate: | 05/16/2009 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 3030 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225200000X | 2287 | SC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.