Provider Demographics
NPI:1467586388
Name:GARDNER, CHERYL M (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:M
Last Name:GARDNER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 DAIRY RD
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-1512
Mailing Address - Country:US
Mailing Address - Phone:321-267-6687
Mailing Address - Fax:321-747-0407
Practice Address - Street 1:3300 DAIRY RD
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-1512
Practice Address - Country:US
Practice Address - Phone:321-267-6687
Practice Address - Fax:321-747-0407
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3409302363LP2300X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004473700Medicaid
FLU6558YMedicare PIN