Healthcare Provider Details

I. General information

NPI: 1043151061
Provider Name (Legal Business Name): KAILIE ANNE GARDNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2026
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2549 JOLLY RD
OKEMOS MI
48864-3678
US

IV. Provider business mailing address

377 THIRD ST
SUNFIELD MI
48890-9769
US

V. Phone/Fax

Practice location:
  • Phone: 517-300-6950
  • Fax:
Mailing address:
  • Phone: 517-743-1569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: