Provider Demographics
NPI:1104349117
Name:GARDENER, LATASHA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:LATASHA
Middle Name:
Last Name:GARDENER
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3871 HARLEM RD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-1946
Mailing Address - Country:US
Mailing Address - Phone:716-681-4088
Mailing Address - Fax:
Practice Address - Street 1:564 NIAGARA ST BLDG 2
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14201-1108
Practice Address - Country:US
Practice Address - Phone:716-882-0366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-21
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY341916363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily