Provider Demographics
NPI:1700861234
Name:GARDNER, MINDI (CNP)
Entity Type:Individual
Prefix:
First Name:MINDI
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10496 MONTGOMERY RD
Mailing Address - Street 2:STE 110
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45242-5223
Mailing Address - Country:US
Mailing Address - Phone:513-791-7572
Mailing Address - Fax:513-791-8240
Practice Address - Street 1:4600 MONTGOMERY RD
Practice Address - Street 2:STE 105
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45212-2697
Practice Address - Country:US
Practice Address - Phone:513-487-5305
Practice Address - Fax:513-487-5317
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH07302-NP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000361570OtherANTHEM BLUE SHIELD
IN200442150Medicaid
OH2412008Medicaid
7707682OtherAETNA
KY78010089Medicaid
KY78010089Medicaid
OHGANP12776Medicare UPIN
P83952Medicare UPIN