Provider Demographics
NPI:1164953709
Name:GARDNER, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
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 1:122 W FRANKLIN AVE
Mailing Address - Street 2:SUITE 510
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-2447
Mailing Address - Country:US
Mailing Address - Phone:612-871-3759
Mailing Address - Fax:612-230-3257
Practice Address - Street 1:122 W FRANKLIN AVE
Practice Address - Street 2:SUITE 510
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-2447
Practice Address - Country:US
Practice Address - Phone:612-871-3759
Practice Address - Fax:612-230-3257
Is Sole Proprietor?:No
Enumeration Date:2017-03-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker