Provider Demographics
NPI:1659597722
Name:GARDNER, CONNIE KAYE (MS)
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:KAYE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MRS
Other - First Name:CONNIE
Other - Middle Name:KAYE
Other - Last Name:SMITH-GARDNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS
Mailing Address - Street 1:P.O. BOX 2461
Mailing Address - Street 2:
Mailing Address - City:SNOWFLAKE
Mailing Address - State:AZ
Mailing Address - Zip Code:85937-2461
Mailing Address - Country:US
Mailing Address - Phone:928-536-3292
Mailing Address - Fax:
Practice Address - Street 1:205 W F BAR LN
Practice Address - Street 2:
Practice Address - City:SNOWFLAKE
Practice Address - State:AZ
Practice Address - Zip Code:85937-5094
Practice Address - Country:US
Practice Address - Phone:928-536-3292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2816225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist