Provider Demographics
NPI:1316930324
Name:GARDNER, CAROL ANN (FNP)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:ANN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2180
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29528-2180
Mailing Address - Country:US
Mailing Address - Phone:843-349-1001
Mailing Address - Fax:843-234-6990
Practice Address - Street 1:2367B CYPRESS CIR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8921
Practice Address - Country:US
Practice Address - Phone:843-349-1001
Practice Address - Fax:843-349-1008
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN1210363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ41341Medicare UPIN
SCAA08277402Medicare ID - Type Unspecified