Provider Demographics
NPI:1083370563
Name:GARDNER, SELENA JOSEPHINA (MHSC, RDN, LDN)
Entity Type:Individual
Prefix:MRS
First Name:SELENA
Middle Name:JOSEPHINA
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MHSC, RDN, LDN
Other - Prefix:
Other - First Name:SELENA
Other - Middle Name:JOSEPHINA
Other - Last Name:RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5261 SHERRY LN
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-3340
Mailing Address - Country:US
Mailing Address - Phone:513-802-1184
Mailing Address - Fax:
Practice Address - Street 1:5261 SHERRY LN
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-3340
Practice Address - Country:US
Practice Address - Phone:513-802-1184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD.09278133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHLD.09278OtherDIETITIAN LICENSE
OH215415178089OtherAMERICAN HEART ASSOCIATION BASIC LIFE SUPPORT
OH18083204OtherSERVSAFE
OH86174429OtherDIETITIAN REGISTRATION