Provider Demographics
NPI:1396211645
Name:GARDNER, LAKEYLA (NP)
Entity Type:Individual
Prefix:
First Name:LAKEYLA
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11247
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94712-2247
Mailing Address - Country:US
Mailing Address - Phone:510-981-4100
Mailing Address - Fax:
Practice Address - Street 1:837 ADDISON ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94710-2047
Practice Address - Country:US
Practice Address - Phone:510-981-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-14
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95017057363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty