Provider Demographics
NPI:1750045712
Name:GARDNER, SHALESSE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:SHALESSE
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3835 N FREEWAY BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-1954
Mailing Address - Country:US
Mailing Address - Phone:916-576-7900
Mailing Address - Fax:
Practice Address - Street 1:8383 WILSHIRE BLVD STE 202
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2432
Practice Address - Country:US
Practice Address - Phone:855-501-1004
Practice Address - Fax:310-432-7065
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-26
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95015664363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health