Basic Information
Provider Information | |||||||||
NPI: | 1811906100 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PHILBROOK | ||||||||
FirstName: | GWENDA | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LAMOREE | ||||||||
OtherFirstName: | GWENDA | ||||||||
OtherMiddleName: | M | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1001 S OHIO ST | ||||||||
Address2: |   | ||||||||
City: | SALINA | ||||||||
State: | KS | ||||||||
PostalCode: | 674015364 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7858276453 | ||||||||
FaxNumber: | 7858231255 | ||||||||
Practice Location | |||||||||
Address1: | 1001 S OHIO ST | ||||||||
Address2: |   | ||||||||
City: | SALINA | ||||||||
State: | KS | ||||||||
PostalCode: | 674015364 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7858276453 | ||||||||
FaxNumber: | 7858231255 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/05/2006 | ||||||||
LastUpdateDate: | 03/12/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/12/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 53-45870 | KS | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 200389600G | 05 | KS |   | MEDICAID |