Provider Demographics
NPI:1558623439
Name:GARDNER, KELLY MARTIN (RN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARTIN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8200 MAURICE ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-9649
Mailing Address - Country:US
Mailing Address - Phone:318-309-3917
Mailing Address - Fax:
Practice Address - Street 1:1035 CRESWELL AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-3917
Practice Address - Country:US
Practice Address - Phone:318-676-5623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-15
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN089405163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health