=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326759135
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAELIE NICOLE GARDNER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2022
-----------------------------------------------------
Last Update Date | 08/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 818 W KING ST STE 101
-----------------------------------------------------
City | OWOSSO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48867-2159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-725-8171
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 818 W KING ST STE 101
-----------------------------------------------------
City | OWOSSO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48867-2159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-725-8171
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 4704341664
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------