=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083299085
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISSY GARDNER NP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2021
-----------------------------------------------------
Last Update Date | 05/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 359 CEDAR TRAIL LN
-----------------------------------------------------
City | HARVEST
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35749-9659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-655-1860
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 359 CEDAR TRAIL LN
-----------------------------------------------------
City | HARVEST
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35749-9659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-655-1860
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 1-136585
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 1-136585
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------