Provider Demographics
NPI:1679939748
Name:GARDNER, IVORINE M (LPN)
Entity Type:Individual
Prefix:
First Name:IVORINE
Middle Name:M
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4007 N UNIVERSITY DR
Mailing Address - Street 2:APT F102
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351-6368
Mailing Address - Country:US
Mailing Address - Phone:954-588-1495
Mailing Address - Fax:
Practice Address - Street 1:4007 N UNIVERSITY DR
Practice Address - Street 2:APT F102
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351-6368
Practice Address - Country:US
Practice Address - Phone:954-588-1495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-05
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5207256164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse