Healthcare Provider Details

I. General information

NPI: 1578183208
Provider Name (Legal Business Name): MR. DONALD GLYN GARDNER II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2020
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 CHINABERRY DR STE 502
BOSSIER CITY LA
71111-2462
US

IV. Provider business mailing address

1000 CHINABERRY DR STE 502
BOSSIER CITY LA
71111-2462
US

V. Phone/Fax

Practice location:
  • Phone: 318-232-2749
  • Fax: 318-620-4031
Mailing address:
  • Phone: 318-232-2749
  • Fax: 318-620-4031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number214187
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number214187
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: