Provider Demographics
NPI:1770806093
Name:GARDNER, DAWN RAE (R,N)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:RAE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:R,N
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 1275
Mailing Address - Street 2:
Mailing Address - City:FORT WASHAKIE
Mailing Address - State:WY
Mailing Address - Zip Code:82514-1275
Mailing Address - Country:US
Mailing Address - Phone:307-840-2537
Mailing Address - Fax:307-332-0131
Practice Address - Street 1:29 BLACK COAL DR
Practice Address - Street 2:
Practice Address - City:FORT WASHAKIE
Practice Address - State:WY
Practice Address - Zip Code:82514-0000
Practice Address - Country:US
Practice Address - Phone:307-840-2537
Practice Address - Fax:307-332-0131
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY19363163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse