Provider Demographics
NPI:1821549858
Name:GARDNER, KATIE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
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 1:5851 W MOORESTOWN RD
Mailing Address - Street 2:
Mailing Address - City:MANTON
Mailing Address - State:MI
Mailing Address - Zip Code:49663
Mailing Address - Country:US
Mailing Address - Phone:586-295-5615
Mailing Address - Fax:
Practice Address - Street 1:5851 W MOORESTOWN RD
Practice Address - Street 2:
Practice Address - City:MANTON
Practice Address - State:MI
Practice Address - Zip Code:49663-9012
Practice Address - Country:US
Practice Address - Phone:586-295-5615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-14
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer