Provider Demographics
NPI:1164657474
Name:VILLELA, GWENDOLYN DENISE (PTA)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:DENISE
Last Name:VILLELA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:GWENDOLYN
Other - Middle Name:DENISE
Other - Last Name:CANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:111 HARRILSON RD
Mailing Address - Street 2:
Mailing Address - City:CHERRYVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28021-9541
Mailing Address - Country:US
Mailing Address - Phone:704-435-4161
Mailing Address - Fax:
Practice Address - Street 1:111 HARRILSON RD
Practice Address - Street 2:
Practice Address - City:CHERRYVILLE
Practice Address - State:NC
Practice Address - Zip Code:28021-9541
Practice Address - Country:US
Practice Address - Phone:704-435-4161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-16
Last Update Date:2009-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3030225200000X
SC2287225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant