Provider Demographics
NPI:1578183208
Name:GARDNER, DONALD GLYN II
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:GLYN
Last Name:GARDNER
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 BLUE FOX CIR
Mailing Address - Street 2:
Mailing Address - City:HAUGHTON
Mailing Address - State:LA
Mailing Address - Zip Code:71037-7707
Mailing Address - Country:US
Mailing Address - Phone:318-401-6258
Mailing Address - Fax:
Practice Address - Street 1:324 BLUE FOX CIR
Practice Address - Street 2:
Practice Address - City:HAUGHTON
Practice Address - State:LA
Practice Address - Zip Code:71037-7707
Practice Address - Country:US
Practice Address - Phone:318-401-6258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-22
Last Update Date:2020-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA214187363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health