Basic Information
| Provider Information | |||||||||
| NPI: | 1861530883 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | GWENDOLYN | ||||||||
| MiddleName: | DIANNE | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3001 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | CHEVERLY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207851189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016182355 | ||||||||
| FaxNumber: | 3016183521 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 HARRY S TRUMAN DRIVE NORTH | ||||||||
| Address2: | |||||||||
| City: | LARGO | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2406772000 | ||||||||
| FaxNumber: | 2406770066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 02/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | R052268 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 402527000 | 05 | MD | MEDICAID |