Provider Demographics
NPI:1285816504
Name:GARDNER- CHIDEBE, PATRICIA ANN (LVN)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:ANN
Last Name:GARDNER- CHIDEBE
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13005 FLORWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-5353
Mailing Address - Country:US
Mailing Address - Phone:310-531-4019
Mailing Address - Fax:
Practice Address - Street 1:13005 FLORWOOD AVE
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-5353
Practice Address - Country:US
Practice Address - Phone:310-531-4019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA192831164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEPS014910Medicare PIN