Provider Demographics
NPI:1457658783
Name:GARDNER, RENEE (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:E3084 BUNKER RD
Mailing Address - Street 2:
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981-8815
Mailing Address - Country:US
Mailing Address - Phone:715-258-9042
Mailing Address - Fax:
Practice Address - Street 1:E3084 BUNKER RD
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-8815
Practice Address - Country:US
Practice Address - Phone:715-258-9042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-23
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI156325-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse