Basic Information
| Provider Information | |||||||||
| NPI: | 1982070785 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GWIN | ||||||||
| FirstName: | LEAH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILFONG | ||||||||
| OtherFirstName: | LEAH | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APN | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 901 PRINCE WILLIAM RD STE A | ||||||||
| Address2: | |||||||||
| City: | DELPHI | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469231759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 901 PRINCE WILLIAM RD STE A | ||||||||
| Address2: | |||||||||
| City: | DELPHI | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469231759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7655643016 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2015 | ||||||||
| LastUpdateDate: | 12/19/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 28197607A | IN | N | Nursing Service Providers | Registered Nurse | 363L00000X | 71005660A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 201313300 | 05 | IN | MEDICAID | 855O | 01 | IN | MEDICARE | OTHER |