Provider Demographics
NPI:1447985254
Name:SCULLARK, GWYNAVIA MONIQUE
Entity type:Individual
Prefix:
First Name:GWYNAVIA
Middle Name:MONIQUE
Last Name:SCULLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:442 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50703-3616
Mailing Address - Country:US
Mailing Address - Phone:319-404-2630
Mailing Address - Fax:
Practice Address - Street 1:442 CENTER ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50703-3616
Practice Address - Country:US
Practice Address - Phone:319-404-2630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1423959374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula