Provider Demographics
NPI:1205407376
Name:GARDNER, MANDIE ROSE (ARNP)
Entity type:Individual
Prefix:
First Name:MANDIE
Middle Name:ROSE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7146 COUNTRY VILLAGE DR SW
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-7062
Mailing Address - Country:US
Mailing Address - Phone:219-384-7104
Mailing Address - Fax:
Practice Address - Street 1:7146 COUNTRY VILLAGE DR SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-7062
Practice Address - Country:US
Practice Address - Phone:219-384-7104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61185174363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health