Provider Demographics
NPI:1639248131
Name:GARDNER, AMY D (FNP-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:D
Last Name:GARDNER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 S. NATIONAL AVE
Mailing Address - Street 2:#540
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5284
Mailing Address - Country:US
Mailing Address - Phone:417-269-2264
Mailing Address - Fax:417-269-2270
Practice Address - Street 1:102 COURTNEY LANE
Practice Address - Street 2:
Practice Address - City:CRANE
Practice Address - State:MO
Practice Address - Zip Code:65633-9192
Practice Address - Country:US
Practice Address - Phone:417-269-2264
Practice Address - Fax:417-269-2270
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO134830363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO425928405Medicaid
MO000081334Medicare PIN
MO425928405Medicaid
MOP68574Medicare UPIN