Provider Demographics
NPI:1376181602
Name:GARDNER, KARIANNE J (ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:KARIANNE
Middle Name:J
Last Name:GARDNER
Suffix:
Gender:F
Credentials:ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4702 VAHALLA DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-3334
Mailing Address - Country:US
Mailing Address - Phone:217-621-1847
Mailing Address - Fax:
Practice Address - Street 1:4702 VAHALLA DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-3334
Practice Address - Country:US
Practice Address - Phone:217-621-1847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0039652255A2300X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty