Provider Demographics
NPI:1114507894
Name:GARDINE, AMANDA (LPN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:GARDINE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6007 5TH AVENUE PL
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-8413
Mailing Address - Country:US
Mailing Address - Phone:308-440-3565
Mailing Address - Fax:
Practice Address - Street 1:6007 5TH AVENUE PL
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68845-8413
Practice Address - Country:US
Practice Address - Phone:308-440-3565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE23213164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse