Provider Demographics
NPI:1689885741
Name:GARDNER, ALYSON (LMP)
Entity Type:Individual
Prefix:
First Name:ALYSON
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3305 W WELLESLEY AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-1681
Mailing Address - Country:US
Mailing Address - Phone:509-991-0199
Mailing Address - Fax:
Practice Address - Street 1:9116 E SPRAGUE AVE APT B
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-3601
Practice Address - Country:US
Practice Address - Phone:509-924-0067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00018157225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist