Provider Demographics
NPI:1194238857
Name:GARDNER, ANDREA DEE (DC)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:DEE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:DEE
Other - Last Name:RAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 700688
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78270-0688
Mailing Address - Country:US
Mailing Address - Phone:210-318-3007
Mailing Address - Fax:210-468-0682
Practice Address - Street 1:15215 SE 272ND ST STE 105
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98042-9918
Practice Address - Country:US
Practice Address - Phone:800-404-6050
Practice Address - Fax:866-313-3397
Is Sole Proprietor?:No
Enumeration Date:2017-11-15
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH61001282111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACH61001282OtherCHIROPRACTIC LICENSE
FLCH12356OtherCHIROPRACTIC LICENSE
IL038.013678OtherCHIROPRACTIC LICENSE