Healthcare Provider Details

I. General information

NPI: 1609479062
Provider Name (Legal Business Name): GWENDOLYN TANNER GARDNER DC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2020
Last Update Date: 04/07/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 BARCLAY CIR SE
MARIETTA GA
30060-2943
US

IV. Provider business mailing address

1415 BARCLAY CIR SE
MARIETTA GA
30060-2943
US

V. Phone/Fax

Practice location:
  • Phone: 770-792-6100
  • Fax: 770-792-6113
Mailing address:
  • Phone: 770-792-6100
  • Fax: 770-792-6113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License NumberCHIR009011
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR009011
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: