Provider Demographics
NPI:1649020058
Name:GARDNER, JANELLE SHERIDAN
Entity type:Individual
Prefix:
First Name:JANELLE
Middle Name:SHERIDAN
Last Name:GARDNER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13822 N STATE ROAD 121
Mailing Address - Street 2:
Mailing Address - City:MACCLENNY
Mailing Address - State:FL
Mailing Address - Zip Code:32063-4370
Mailing Address - Country:US
Mailing Address - Phone:904-514-3285
Mailing Address - Fax:
Practice Address - Street 1:5533 SW 64TH ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-9608
Practice Address - Country:US
Practice Address - Phone:352-271-5967
Practice Address - Fax:352-271-5968
Is Sole Proprietor?:No
Enumeration Date:2024-03-26
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6481152W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program