Provider Demographics
NPI:1033791843
Name:GARDNER, MARY JUDITH (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JUDITH
Last Name:GARDNER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:655 KENMOOR AVE SE STE 101
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8622
Mailing Address - Country:US
Mailing Address - Phone:616-900-9911
Mailing Address - Fax:616-900-9862
Practice Address - Street 1:655 KENMOOR AVE SE STE 101
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8622
Practice Address - Country:US
Practice Address - Phone:616-900-9911
Practice Address - Fax:616-900-9862
Is Sole Proprietor?:No
Enumeration Date:2021-04-22
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704281984363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology