Basic Information
| Provider Information | |||||||||
| NPI: | 1255824959 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANES | ||||||||
| FirstName: | GWENDOLYN | ||||||||
| MiddleName: | |||||||||
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| Credential: | REGISTERED NURSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11354 VIA RANCHO SAN DIEGO UNIT D | ||||||||
| Address2: | |||||||||
| City: | EL CAJON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920195203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6193099598 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 995 GATEWAY CENTER WAY STE 300 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921024550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6193982156 | ||||||||
| FaxNumber: | 6193982168 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2018 | ||||||||
| LastUpdateDate: | 04/05/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WG0000X | RN655020 | CA | Y | Nursing Service Providers | Registered Nurse | General Practice |
ID Information
| ID | Type | State | Issuer | Description | A2634637 | 01 | CA | DRIVER LICENSE | OTHER |