Provider Demographics
NPI:1528380847
Name:GARDNER, CHRISTINE ANN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:ANN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3157 FOX RD
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13215-9744
Mailing Address - Country:US
Mailing Address - Phone:315-673-4464
Mailing Address - Fax:
Practice Address - Street 1:2105 W GENESEE ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13219-1698
Practice Address - Country:US
Practice Address - Phone:315-468-3239
Practice Address - Fax:315-468-2917
Is Sole Proprietor?:No
Enumeration Date:2010-03-01
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211405-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY211405-1OtherLPN LICENSE