Provider Demographics
NPI:1346812013
Name:GARDNER, STEPHANIE JEANNETTE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JEANNETTE
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 1:3970 HIGHWAY 118
Mailing Address - Street 2:
Mailing Address - City:DRESDEN
Mailing Address - State:TN
Mailing Address - Zip Code:38225-5905
Mailing Address - Country:US
Mailing Address - Phone:731-514-5935
Mailing Address - Fax:
Practice Address - Street 1:130 COMMONS DR
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:TN
Practice Address - Zip Code:38237-3879
Practice Address - Country:US
Practice Address - Phone:731-587-5138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000029252363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics