Provider Demographics
NPI:1780862755
Name:GARDNER, NICHOLE MARIE (ND)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:MARIE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3012 S DURANGO DR
Mailing Address - Street 2:STE 2 DIAGNOSTIC CENTER OF MEDICINE
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117
Mailing Address - Country:US
Mailing Address - Phone:702-366-1655
Mailing Address - Fax:702-385-4955
Practice Address - Street 1:3012 S DURANGO DR
Practice Address - Street 2:STE 1 DIAGNOSTIC CENTER OF MEDICINE
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117
Practice Address - Country:US
Practice Address - Phone:702-366-0640
Practice Address - Fax:702-366-9075
Is Sole Proprietor?:No
Enumeration Date:2008-02-01
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANT00001585175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
WANT00001585OtherSTATE LICENSE