Provider Demographics
NPI:1154909562
Name:GARDNER, MESHAWN M (RN)
Entity type:Individual
Prefix:
First Name:MESHAWN
Middle Name:M
Last Name:GARDNER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-3373
Mailing Address - Country:US
Mailing Address - Phone:262-498-8045
Mailing Address - Fax:262-456-7436
Practice Address - Street 1:2814 S 108TH ST
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-3224
Practice Address - Country:US
Practice Address - Phone:414-885-3525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI166334-030163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health