Healthcare Provider Details

I. General information

NPI: 1023590320
Provider Name (Legal Business Name): JENNIFER MARIE GARDNER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2018
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVENUE
FARMINGTON CT
06030-8040
US

IV. Provider business mailing address

263 FARMINGTON AVE
FARMINGTON CT
06030-8040
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-2100
  • Fax: 860-679-4815
Mailing address:
  • Phone: 860-679-2100
  • Fax: 860-679-4815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number007819
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number12.007819
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11018163
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number007819
License Number StateCT
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95020321
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: