Provider Demographics
NPI:1639721897
Name:ENGEN, GWENNAN DAEL (FNP-C)
Entity type:Individual
Prefix:
First Name:GWENNAN
Middle Name:DAEL
Last Name:ENGEN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1840 PLANTERS ROW DR SW
Mailing Address - Street 2:
Mailing Address - City:BYRON CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49315-8177
Mailing Address - Country:US
Mailing Address - Phone:616-422-6170
Mailing Address - Fax:
Practice Address - Street 1:5900 BYRON CENTER AVE SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9606
Practice Address - Country:US
Practice Address - Phone:616-252-5126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704277975163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty