Provider Demographics
NPI:1225410665
Name:GARDENER, GRACE (MDA, RDN, LDN)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:GARDENER
Suffix:
Gender:F
Credentials:MDA, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11516 BRIGHTON CT
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-8220
Mailing Address - Country:US
Mailing Address - Phone:702-738-4129
Mailing Address - Fax:
Practice Address - Street 1:11516 BRIGHTON CT
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-8220
Practice Address - Country:US
Practice Address - Phone:702-738-4129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-22
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA078676133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered