Provider Demographics
NPI:1801908447
Name:GARDNER, AMY GLEASON (MS, RD)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:GLEASON
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:MS
Other - First Name:AMY
Other - Middle Name:CYNTHIA
Other - Last Name:GLEASON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RD
Mailing Address - Street 1:1400 CENTRE ST STE 207
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02459-2415
Mailing Address - Country:US
Mailing Address - Phone:617-332-2282
Mailing Address - Fax:617-244-0884
Practice Address - Street 1:10 LANGLEY RD
Practice Address - Street 2:SUITE 300
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02459-1972
Practice Address - Country:US
Practice Address - Phone:617-332-2282
Practice Address - Fax:617-244-0884
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2055133V00000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAGLMT0470Medicare ID - Type UnspecifiedMNT