Healthcare Provider Details

I. General information

NPI: 1356125371
Provider Name (Legal Business Name): KAYLA GARDNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 HARDING AVE STE 1
EAU CLAIRE WI
54701-4861
US

IV. Provider business mailing address

1720 HARDING AVE STE 1
EAU CLAIRE WI
54701-4861
US

V. Phone/Fax

Practice location:
  • Phone: 715-832-2200
  • Fax:
Mailing address:
  • Phone: 715-832-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number14396-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: