Provider Demographics
NPI:1477272003
Name:GARDNER, ROBIN LYNN
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:LYNN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15156 STATE HIGHWAY 149
Mailing Address - Street 2:
Mailing Address - City:WEST FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:62896-4414
Mailing Address - Country:US
Mailing Address - Phone:618-218-3022
Mailing Address - Fax:
Practice Address - Street 1:15156 STATE HIGHWAY 149
Practice Address - Street 2:
Practice Address - City:WEST FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:62896-4414
Practice Address - Country:US
Practice Address - Phone:618-218-3022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057002736224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant