MEDICARE: MISS JENNIFER L GARDNER LPN

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	374U00000X	Home Health Aide	291818	WI
2	376K00000X	Nurse's Aide	291818	WI
3	164W00000X	Licensed Practical Nurse	312658-31	WI

General Provider Information

NPI Number	:	1548527740
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS JENNIFER L GARDNER LPN

Provider Business Mailing Address
First Line	:	713 MATHER ST
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54303-3559
Country	:	US
Telephone Number	:	920-309-1486
Fax Number	:

Provider Business Practice Location Address
First Line	:	713 MATHER ST
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54303-3559
Country	:	US
Telephone Number	:	920-309-1486
Fax Number	:

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

Provider Enumeration Date	:	04/12/2012
Last Update Date	:	05/21/2012

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