Provider Demographics
NPI:1982176327
Name:GARDNER, JENNIFER ERCLE (RN,IBCLC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ERCLE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:RN,IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 DENNING RD
Mailing Address - Street 2:
Mailing Address - City:COPENHAGEN
Mailing Address - State:NY
Mailing Address - Zip Code:13626-3403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:391 DENNING RD
Practice Address - Street 2:
Practice Address - City:COPENHAGEN
Practice Address - State:NY
Practice Address - Zip Code:13626-3403
Practice Address - Country:US
Practice Address - Phone:315-778-6280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-26
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYL-151282163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Single Specialty