Provider Demographics
NPI:1184440273
Name:GARDNER, LENITA W (CRSS,CHW)
Entity type:Individual
Prefix:
First Name:LENITA
Middle Name:W
Last Name:GARDNER
Suffix:
Gender:F
Credentials:CRSS,CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 TOWER DR # B301
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-1340
Mailing Address - Country:US
Mailing Address - Phone:312-200-4288
Mailing Address - Fax:
Practice Address - Street 1:3901 TOWER DR # B301
Practice Address - Street 2:
Practice Address - City:RICHTON PARK
Practice Address - State:IL
Practice Address - Zip Code:60471-1340
Practice Address - Country:US
Practice Address - Phone:312-200-4288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-23
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL172V00000X
IL38624175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty
No172V00000XOther Service ProvidersCommunity Health Worker