Provider Demographics
NPI:1356779219
Name:GARDNER, GRANT R (LPN)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:R
Last Name:GARDNER
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5907 STATE HIGHWAY 51
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON FLATS
Mailing Address - State:NY
Mailing Address - Zip Code:13315-2009
Mailing Address - Country:US
Mailing Address - Phone:607-965-6620
Mailing Address - Fax:
Practice Address - Street 1:5907 STATE HIGHWAY 51
Practice Address - Street 2:
Practice Address - City:BURLINGTON FLATS
Practice Address - State:NY
Practice Address - Zip Code:13315-2009
Practice Address - Country:US
Practice Address - Phone:607-965-6620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-30
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY249313-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse