MEDICARE: NICHOLE GARDNER

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
1	246RP1900X	Phlebotomy Technician

General Provider Information

NPI Number	:	1467160549
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLE GARDNER

Provider Business Mailing Address
First Line	:	520 PEMBROKE DR
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62223-3222
Country	:	US
Telephone Number	:	618-558-9906
Fax Number	:

Provider Business Practice Location Address
First Line	:	520 PEMBROKE DR
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62223-3222
Country	:	US
Telephone Number	:	618-558-9906
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2022
Last Update Date	:	11/08/2022

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Directions to “ NICHOLE GARDNER ” Practice Location

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