Basic Information
| Provider Information | |||||||||
| NPI: | 1649564121 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATTOX | ||||||||
| FirstName: | GWEN | ||||||||
| MiddleName: | D. | ||||||||
| NamePrefix: | |||||||||
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| Credential: | LVN | ||||||||
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| Mailing Information | |||||||||
| Address1: | P O BOX 2087 | ||||||||
| Address2: | |||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953416217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093816819 | ||||||||
| FaxNumber: | 2093816871 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 E 15TH ST | ||||||||
| Address2: | |||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953416217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093816819 | ||||||||
| FaxNumber: | 2093816871 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2011 | ||||||||
| LastUpdateDate: | 01/27/2016 | ||||||||
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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 | 164X00000X | 236591 | CA | Y | Nursing Service Providers | Licensed Vocational Nurse |
No ID Information.