Provider Demographics
NPI:1356779375
Name:GARDNER, JOANNE
Entity type:Individual
Prefix:
First Name:JOANNE
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751274
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1274
Mailing Address - Country:US
Mailing Address - Phone:919-620-4491
Mailing Address - Fax:800-782-6945
Practice Address - Street 1:3475 ERWIN ROAD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-2664
Practice Address - Country:US
Practice Address - Phone:919-660-6826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-30
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL004224133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered