Healthcare Provider Details

I. General information

NPI: 1689827966
Provider Name (Legal Business Name): JENNIFER L GARDNER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2008
Last Update Date: 10/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 GREAT PLAIN ROAD
ARAPAHOE WY
82510
US

IV. Provider business mailing address

3914 TAM-O-SHANTER
RIVERTON WY
82501
US

V. Phone/Fax

Practice location:
  • Phone: 307-856-9281
  • Fax: 307-856-1630
Mailing address:
  • Phone: 307-856-1564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number25376
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: