Provider Demographics
NPI:1750049995
Name:GARDNER, ALEXANDRA RENEA NUSSBAUMER (RDN, LDN, CLC)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:RENEA NUSSBAUMER
Last Name:GARDNER
Suffix:
Gender:F
Credentials:RDN, LDN, CLC
Other - Prefix:
Other - First Name:ALEXANDRA
Other - Middle Name:RENEA
Other - Last Name:NUSSBAUMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:829 S CIRCLE DR APT 110D
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-2338
Mailing Address - Country:US
Mailing Address - Phone:865-659-1696
Mailing Address - Fax:
Practice Address - Street 1:6829 MOUNTAIN SHADOW DR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37918-6317
Practice Address - Country:US
Practice Address - Phone:865-659-1696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-06
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4200133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered