Healthcare Provider Details

I. General information

NPI: 1275171167
Provider Name (Legal Business Name): BONNIE L GARDNER CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2019
Last Update Date: 12/24/2024
Certification Date: 12/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2003 MEDICAL PKWY STE 150
ANNAPOLIS MD
21401-0317
US

IV. Provider business mailing address

2000 MEDICAL PKWY STE 409
ANNAPOLIS MD
21401-3746
US

V. Phone/Fax

Practice location:
  • Phone: 443-481-1199
  • Fax: 443-481-1495
Mailing address:
  • Phone: 667-204-7212
  • Fax: 443-481-4151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR181978
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: