Provider Demographics
NPI:1316412919
Name:GARDNER, MARY LOUISE (FNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6513 PAYTON DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76131-1212
Mailing Address - Country:US
Mailing Address - Phone:682-365-1835
Mailing Address - Fax:
Practice Address - Street 1:1001 W EAGLE DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3745
Practice Address - Country:US
Practice Address - Phone:940-627-7440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP139096363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily