Healthcare Provider Details

I. General information

NPI: 1457148314
Provider Name (Legal Business Name): REESE GARDEA
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2025
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 GLENEAGLES CT STE 100
TOWSON MD
21286-2204
US

IV. Provider business mailing address

1435 NICHOLASVILLE RD APT 2104
LEXINGTON KY
40503-1187
US

V. Phone/Fax

Practice location:
  • Phone: 410-449-2849
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: