Provider Demographics
NPI:1871934836
Name:KING, GWENDOLYN COLTRANE (PTA)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:COLTRANE
Last Name:KING
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1327 TOLLIE WELDON RD
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27537-9171
Mailing Address - Country:US
Mailing Address - Phone:252-430-6503
Mailing Address - Fax:
Practice Address - Street 1:566 RUIN CREEK RD
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-2927
Practice Address - Country:US
Practice Address - Phone:252-410-3708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-07
Last Update Date:2013-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1903225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant