Healthcare Provider Details

I. General information

NPI: 1730997784
Provider Name (Legal Business Name): NAELAH GARDNER PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2024
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W 6TH AVE
GARY IN
46402
US

IV. Provider business mailing address

4112 WABASH AVE
HAMMOND IN
46327-1220
US

V. Phone/Fax

Practice location:
  • Phone: 219-885-4264
  • Fax:
Mailing address:
  • Phone: 773-387-5528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberPMH11240046
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: