Provider Demographics
NPI:1255032918
Name:GARDNER, ANGELA (QBHS)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:QBHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37721 VINE ST STE 1
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-6256
Mailing Address - Country:US
Mailing Address - Phone:440-525-5305
Mailing Address - Fax:216-525-5238
Practice Address - Street 1:37721 VINE ST STE 1
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-6256
Practice Address - Country:US
Practice Address - Phone:440-525-5305
Practice Address - Fax:216-525-5238
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-10
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator