Provider Demographics
NPI:1104100486
Name:GARDNER, ANDREA SIMONE
Entity type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:SIMONE
Last Name:GARDNER
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 1:18447 LOST KNIFE CIR APT 304
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY VILLAGE
Mailing Address - State:MD
Mailing Address - Zip Code:20886-0408
Mailing Address - Country:US
Mailing Address - Phone:240-449-6935
Mailing Address - Fax:
Practice Address - Street 1:18447 LOST KNIFE CIR APT 304
Practice Address - Street 2:
Practice Address - City:MONTGOMERY VILLAGE
Practice Address - State:MD
Practice Address - Zip Code:20886-0408
Practice Address - Country:US
Practice Address - Phone:240-449-6935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-04
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD372600000X, 374U00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide