MEDICARE: STACEY 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	164W00000X	Licensed Practical Nurse	LP033900	AZ

General Provider Information

NPI Number	:	1598619538
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY GARDNER

Provider Business Mailing Address
First Line	:	4709 S 181ST AVE
Second Line	:
City	:	GOODYEAR
State	:	AZ
Zip	:	85338-5941
Country	:	US
Telephone Number	:	602-214-1101
Fax Number	:

Provider Business Practice Location Address
First Line	:	19871 W FREMONT RD
Second Line	:
City	:	BUCKEYE
State	:	AZ
Zip	:	85326-9512
Country	:	US
Telephone Number	:	602-214-1101
Fax Number	:

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

Provider Enumeration Date	:	02/25/2026
Last Update Date	:	02/25/2026

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Directions to “ STACEY GARDNER ” Practice Location

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