Provider Demographics
NPI:1710419163
Name:GARDNER, LEORA KATRINA
Entity Type:Individual
Prefix:
First Name:LEORA
Middle Name:KATRINA
Last Name:GARDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 EMMANUEL CT NW
Mailing Address - Street 2:APT 203
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20001-3483
Mailing Address - Country:US
Mailing Address - Phone:571-264-8282
Mailing Address - Fax:
Practice Address - Street 1:616 EMMANUEL CT NW
Practice Address - Street 2:APT 203
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20001-3483
Practice Address - Country:US
Practice Address - Phone:571-264-8282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant