Provider Demographics
NPI:1831836170
Name:GARDENER, KEDISHA RUCHEL (FNP)
Entity type:Individual
Prefix:MS
First Name:KEDISHA
Middle Name:RUCHEL
Last Name:GARDENER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1633 ANCONIA CV
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-0138
Mailing Address - Country:US
Mailing Address - Phone:260-440-0168
Mailing Address - Fax:
Practice Address - Street 1:600 TRAIL RIDGE RD
Practice Address - Street 2:
Practice Address - City:ALBION
Practice Address - State:IN
Practice Address - Zip Code:46701-1541
Practice Address - Country:US
Practice Address - Phone:260-440-0168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71012558A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily