Provider Demographics
NPI:1952484933
Name:GARDNER, MARY E (ANP,FNP,CNM)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:E
Last Name:GARDNER
Suffix:
Gender:F
Credentials:ANP,FNP,CNM
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:HENNESSY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP,FNP,CNM
Mailing Address - Street 1:243 ELM ST
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:NH
Mailing Address - Zip Code:03743-4921
Mailing Address - Country:US
Mailing Address - Phone:907-388-0876
Mailing Address - Fax:
Practice Address - Street 1:243 ELM ST
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:NH
Practice Address - Zip Code:03743-4921
Practice Address - Country:US
Practice Address - Phone:603-542-7771
Practice Address - Fax:603-542-1153
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK13138367A00000X, 363LF0000X
NH067423363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKS17912Medicare UPIN
AKK153097Medicare ID - Type Unspecified
AKK153097Medicare ID - Type Unspecified