Provider Demographics
NPI:1295029676
Name:GARDINE, MARY JANE (LPN)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JANE
Last Name:GARDINE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10438 744 RD
Mailing Address - Street 2:
Mailing Address - City:BERTRAND
Mailing Address - State:NE
Mailing Address - Zip Code:68927-3561
Mailing Address - Country:US
Mailing Address - Phone:308-472-5144
Mailing Address - Fax:
Practice Address - Street 1:10438 744 RD
Practice Address - Street 2:
Practice Address - City:BERTRAND
Practice Address - State:NE
Practice Address - Zip Code:68927-3561
Practice Address - Country:US
Practice Address - Phone:308-472-5144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-03
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE10842164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse