Healthcare Provider Details

I. General information

NPI: 1033791843
Provider Name (Legal Business Name): MARY JUDITH GARDNER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2021
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 ENCINITAS BLVD STE 106
ENCINITAS CA
92024-3738
US

IV. Provider business mailing address

3927 WARING RD STE C
OCEANSIDE CA
92056-4458
US

V. Phone/Fax

Practice location:
  • Phone: 619-703-7220
  • Fax: 619-703-7221
Mailing address:
  • Phone: 619-703-7220
  • Fax: 619-703-7221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number4704281984
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: