Provider Demographics
NPI:1871891200
Name:GARDINER, CONNIE M
Entity type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:M
Last Name:GARDINER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:M
Other - Last Name:GARDINER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:2550 EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-7031
Mailing Address - Country:US
Mailing Address - Phone:608-436-3243
Mailing Address - Fax:
Practice Address - Street 1:2550 EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-7031
Practice Address - Country:US
Practice Address - Phone:608-436-3243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-09
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI345389164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse