Provider Demographics
NPI:1396290748
Name:GARDNER, DENICE LONG (NNP-BC)
Entity type:Individual
Prefix:MRS
First Name:DENICE
Middle Name:LONG
Last Name:GARDNER
Suffix:
Gender:F
Credentials:NNP-BC
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 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1215 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912
Practice Address - Country:US
Practice Address - Phone:517-364-2468
Practice Address - Fax:517-364-3994
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-15
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704366904363LN0000X
WAAP60699163363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatalGroup - Single Specialty