Provider Demographics
NPI:1508191297
Name:GARDNER, DIANNA MARIE (LAC)
Entity Type:Individual
Prefix:
First Name:DIANNA
Middle Name:MARIE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:MARIE
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:637 1ST ST
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-3211
Mailing Address - Country:US
Mailing Address - Phone:707-590-3554
Mailing Address - Fax:
Practice Address - Street 1:637 1ST ST
Practice Address - Street 2:
Practice Address - City:BENICIA
Practice Address - State:CA
Practice Address - Zip Code:94510-3211
Practice Address - Country:US
Practice Address - Phone:707-590-3554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-13
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2549171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist