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General NPI Number Information
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NPI Number | 1609241488
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Entity Type | Organization
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Legal Business Name | K A GARDNER PLLC
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Dates
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Enumeration Date | 12/05/2015
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Last Update Date | 12/05/2015
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Provider Practice Location Address
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Address Line | 3109 6TH AVE STE B
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City | FORT WORTH
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State | TX
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Zip | 76110-3800
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Country | US
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Telephone | 682-312-7339
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Fax |
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Provider Business Mailing Address
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Address Line | 1210 POWDER RIVER TRL
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City | SOUTHLAKE
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State | TX
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Zip | 76092-3231
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | KIMBERLEY GARDNER
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Credential | PMHNP
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Telephone | 817-269-1169
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | AP129382
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License Number State | TX
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