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NPI Code Detail

MEDICARE: KELLY GARDINER

MEDICARE: KELLY GARDINER
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363L00000XNurse Practitioner4704170979MI

General Provider Information

NPI Number : 1447294970
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELLY GARDINER
Provider Business Mailing Address
First Line : 12871 E JEFFERSON AVE
Second Line :
City : DETROIT
State : MI
Zip : 48215-2754
Country : US
Telephone Number : 313-821-3900
Fax Number : 313-217-4590
Provider Business Practice Location Address
First Line : 12871 E JEFFERSON AVE
Second Line :
City : DETROIT
State : MI
Zip : 48215-2754
Country : US
Telephone Number : 313-821-3900
Fax Number : 313-217-4590
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/15/2006
Last Update Date : 02/25/2020

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Directions to “ KELLY GARDINER ” Practice Location

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