Provider Demographics
NPI:1144888488
Name:GARDNER, DESTINEE MARKIA
Entity type:Individual
Prefix:
First Name:DESTINEE
Middle Name:MARKIA
Last Name:GARDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 332
Mailing Address - Street 2:
Mailing Address - City:ROBERSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27871-0332
Mailing Address - Country:US
Mailing Address - Phone:252-902-4606
Mailing Address - Fax:
Practice Address - Street 1:525 SEVILLE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-4890
Practice Address - Country:US
Practice Address - Phone:252-814-3089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-02
Last Update Date:2019-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty