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General NPI Number Information
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NPI Number | 1609479062
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Entity Type | Individual
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Provider Name | GWENDOLYN TANNER GARDNER DC
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Gender | Female
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Dates
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Enumeration Date | 11/18/2020
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Last Update Date | 04/07/2021
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Provider Practice Location Address
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Address Line | 1415 BARCLAY CIR SE
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City | MARIETTA
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State | GA
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Zip | 30060-2943
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Country | US
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Telephone | 770-792-6100
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Fax | 770-792-6113
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Provider Business Mailing Address
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Address Line | 1415 BARCLAY CIR SE
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City | MARIETTA
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State | GA
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Zip | 30060-2943
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Country | US
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Telephone | 770-792-6100
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Fax | 770-792-6113
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NN1001X
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Taxonomy Name | Nutrition Chiropractor
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License Number | CHIR009011
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CHIR009011
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License Number State | GA
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