Provider Demographics
NPI:1205076403
Name:GARDINER, LORI WILLIAMS (NP)
Entity type:Individual
Prefix:MRS
First Name:LORI
Middle Name:WILLIAMS
Last Name:GARDINER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:WILLIAMS
Other - Last Name:CLAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:100 N HOWARD ST STE R
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-0508
Mailing Address - Country:US
Mailing Address - Phone:985-323-6420
Mailing Address - Fax:
Practice Address - Street 1:950 BROADWAY STE 404
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-4427
Practice Address - Country:US
Practice Address - Phone:985-323-6420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-27
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP05721363LF0000X
AR216424363LP0808X
WAAP61412596363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAAP05721OtherSTATE LICENSE
LA1422541Medicaid
LAAP05721OtherSTATE LICENSE