Provider Demographics
NPI:1639467814
Name:GARDNER, LISA A (RN, BSN, CCM)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:A
Last Name:GARDNER
Suffix:
Gender:F
Credentials:RN, BSN, CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12150 LOFT CT
Mailing Address - Street 2:
Mailing Address - City:BRISTOW
Mailing Address - State:VA
Mailing Address - Zip Code:20136-1230
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12150 LOFT CT
Practice Address - Street 2:
Practice Address - City:BRISTOW
Practice Address - State:VA
Practice Address - Zip Code:20136-1230
Practice Address - Country:US
Practice Address - Phone:412-576-2106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001221437163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse