Provider Demographics
NPI:1043672165
Name:GARDNER, TIMOTHY (LPN)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:GARDNER
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1485 E 34TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-2601
Mailing Address - Country:US
Mailing Address - Phone:347-913-9447
Mailing Address - Fax:
Practice Address - Street 1:1485 E 34TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-2601
Practice Address - Country:US
Practice Address - Phone:347-913-9447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-28
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3248863140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric