Healthcare Provider Details

I. General information

NPI: 1295116747
Provider Name (Legal Business Name): NICOLE GARDNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2015
Last Update Date: 06/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5447 SOUTH DURANGO DRIVE
LAS VEGAS NV
89113
US

IV. Provider business mailing address

9932 CAPE MAY ST
LAS VEGAS NV
89141
US

V. Phone/Fax

Practice location:
  • Phone: 702-222-0034
  • Fax: 702-222-0659
Mailing address:
  • Phone: 304-376-8600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6911-S
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: