Provider Demographics
NPI:1407201213
Name:GARDNER, TAMMY LYNN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:LYNN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 W UTICA ST
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-3031
Mailing Address - Country:US
Mailing Address - Phone:315-342-1390
Mailing Address - Fax:315-342-3810
Practice Address - Street 1:104 W UTICA ST
Practice Address - Street 2:SUITE 1A
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-3031
Practice Address - Country:US
Practice Address - Phone:315-342-1390
Practice Address - Fax:315-342-3810
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-29
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY234379-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse