Provider Demographics
NPI:1740821354
Name:GARDNER, LAVONNE ELAINE
Entity type:Individual
Prefix:MRS
First Name:LAVONNE
Middle Name:ELAINE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAVONNE
Other - Middle Name:ELAINE
Other - Last Name:MOELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:209 ALDABA CIRCLE NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-0837
Mailing Address - Country:US
Mailing Address - Phone:780-466-9757
Mailing Address - Fax:
Practice Address - Street 1:209 ALDABA CIRCLE NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-0837
Practice Address - Country:US
Practice Address - Phone:780-466-9757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider