Provider Demographics
NPI:1700404001
Name:GARDINI, KATHY ANNETT (FPA-C)
Entity Type:Individual
Prefix:MS
First Name:KATHY
Middle Name:ANNETT
Last Name:GARDINI
Suffix:
Gender:F
Credentials:FPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1914 BROOKHAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-3626
Mailing Address - Country:US
Mailing Address - Phone:718-869-7923
Mailing Address - Fax:718-869-8701
Practice Address - Street 1:1914 BROOKHAVEN AVE
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-3626
Practice Address - Country:US
Practice Address - Phone:718-869-7923
Practice Address - Fax:718-869-8701
Is Sole Proprietor?:No
Enumeration Date:2020-07-13
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0247175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1346274537Medicaid