Provider Demographics
NPI:1780135483
Name:GARDNER, GENEVIEVE LYKE (DPT)
Entity type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:LYKE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76498 DEERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:YULEE
Mailing Address - State:FL
Mailing Address - Zip Code:32097-1603
Mailing Address - Country:US
Mailing Address - Phone:803-206-0565
Mailing Address - Fax:
Practice Address - Street 1:70 LINDSEY LN
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-1635
Practice Address - Country:US
Practice Address - Phone:912-510-6104
Practice Address - Fax:912-882-6137
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-18
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT31770225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist