Provider Demographics
NPI:1609479062
Name:GARDNER, GWENDOLYN TANNER (DC)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:TANNER
Last Name:GARDNER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 BARCLAY CIR SE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-2943
Mailing Address - Country:US
Mailing Address - Phone:770-792-6100
Mailing Address - Fax:770-792-6113
Practice Address - Street 1:1415 BARCLAY CIR SE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-2943
Practice Address - Country:US
Practice Address - Phone:770-792-6100
Practice Address - Fax:770-792-6113
Is Sole Proprietor?:No
Enumeration Date:2020-11-18
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR009011111NN1001X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NN1001XChiropractic ProvidersChiropractorNutrition