Provider Demographics
NPI:1932075173
Name:GARDNER, MARISA CAREY
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:CAREY
Last Name:GARDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LUMANA
Other - Middle Name:
Other - Last Name:VITA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1725 SEXTONVIEW LN
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-9436
Mailing Address - Country:US
Mailing Address - Phone:925-819-6163
Mailing Address - Fax:
Practice Address - Street 1:1725 SEXTONVIEW LN
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-9436
Practice Address - Country:US
Practice Address - Phone:925-819-6163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-15
Last Update Date:2025-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula