Provider Demographics
NPI:1235898685
Name:GARDNER, MARY CAROLE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CAROLE
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 1:1700 E ASH ST STE 201
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27530-4097
Mailing Address - Country:US
Mailing Address - Phone:919-583-9329
Mailing Address - Fax:
Practice Address - Street 1:1700 E ASH ST STE 201
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27530-4097
Practice Address - Country:US
Practice Address - Phone:919-583-9329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC87493164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse