Healthcare Provider Details

I. General information

NPI: 1548246085
Provider Name (Legal Business Name): CAMILLE MERCEDES GARDNER-BEASLEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAMILLE MERCEDES GARDNER MD

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 04/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040A JACKSON AVE
JOINT BASE LEWIS MCCHORD WA
98431-0001
US

IV. Provider business mailing address

10444 LONGMIRE RD
JOINT BASE LEWIS MCCHORD WA
98433-1357
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-1110
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number200700182
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMEDS7564
License Number StateAK
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7564
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: