Provider Demographics
NPI:1972929040
Name:GARDNER, AMY
Entity Type:Individual
Prefix:
First Name:AMY
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 1:18220 WINSLOW RD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-4809
Mailing Address - Country:US
Mailing Address - Phone:216-336-5608
Mailing Address - Fax:
Practice Address - Street 1:18220 WINSLOW RD
Practice Address - Street 2:
Practice Address - City:SHAKER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44122-4809
Practice Address - Country:US
Practice Address - Phone:216-336-5608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-12
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401620330314374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide