Healthcare Provider Details

I. General information

NPI: 1528054152
Provider Name (Legal Business Name): BRAD VANCE GARDNER FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 05/03/2023
Certification Date: 05/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 SPRUCE ST
BELMONT NC
28012-3370
US

IV. Provider business mailing address

PO BOX 744786
ATLANTA GA
30374-4786
US

V. Phone/Fax

Practice location:
  • Phone: 704-825-5333
  • Fax: 704-825-1751
Mailing address:
  • Phone: 48-342-4507
  • Fax: 704-671-5331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number201403
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201403
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: