Provider Demographics
NPI:1447294970
Name:GARDINER, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GARDINER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12871 E JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48215-2754
Mailing Address - Country:US
Mailing Address - Phone:313-821-3900
Mailing Address - Fax:313-217-4590
Practice Address - Street 1:12871 E JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48215-2754
Practice Address - Country:US
Practice Address - Phone:313-821-3900
Practice Address - Fax:313-217-4590
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704170979363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP34848Medicare UPIN