Provider Demographics
NPI:1477615128
Name:GARDNER, ANITA MICHELLE (NP)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:MICHELLE
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 1:23451 MADISON ST
Mailing Address - Street 2:STE 340
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4763
Mailing Address - Country:US
Mailing Address - Phone:310-373-6864
Mailing Address - Fax:310-373-9547
Practice Address - Street 1:23451 MADISON ST
Practice Address - Street 2:STE 340
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4763
Practice Address - Country:US
Practice Address - Phone:310-373-6864
Practice Address - Fax:310-373-9547
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CANP14153363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP14153OtherNURSE PRACTITIONER