Provider Demographics
NPI:1538438379
Name:MARKS, GWEN COLLEEN (LPN)
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:COLLEEN
Last Name:MARKS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:469 INDIAN COVE ROAD
Mailing Address - Street 2:PO BOX 293
Mailing Address - City:MORAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:13118-3492
Mailing Address - Country:US
Mailing Address - Phone:315-224-8027
Mailing Address - Fax:
Practice Address - Street 1:469 INDIAN COVE RD
Practice Address - Street 2:
Practice Address - City:MORAVIA
Practice Address - State:NY
Practice Address - Zip Code:13118-3492
Practice Address - Country:US
Practice Address - Phone:315-224-8027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-23
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY268534-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse