Provider Demographics
NPI:1396253241
Name:GARDNER, JULIE (FNP)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:
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 1:104 GRANFIELD CT
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-5523
Mailing Address - Country:US
Mailing Address - Phone:601-278-1535
Mailing Address - Fax:
Practice Address - Street 1:971 LAKELAND DR STE 1460
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4621
Practice Address - Country:US
Practice Address - Phone:601-982-3202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-12
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902476363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily