Provider Demographics
NPI:1578063061
Name:GARDEA, CIERRA RAYE (LVN)
Entity Type:Individual
Prefix:MISS
First Name:CIERRA
Middle Name:RAYE
Last Name:GARDEA
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4709 TAFT BLVD APT 103
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-5003
Mailing Address - Country:US
Mailing Address - Phone:940-923-8586
Mailing Address - Fax:
Practice Address - Street 1:4709 TAFT BLVD APT 103
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-5003
Practice Address - Country:US
Practice Address - Phone:940-923-8585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX341212164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Single Specialty