Provider Demographics
NPI:1588263529
Name:GARDNER, DEBORA ANN
Entity type:Individual
Prefix:
First Name:DEBORA
Middle Name:ANN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24397 STATE ROUTE 511
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:44090-9232
Mailing Address - Country:US
Mailing Address - Phone:440-371-9086
Mailing Address - Fax:
Practice Address - Street 1:24397 STATE ROUTE 511
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:OH
Practice Address - Zip Code:44090-9232
Practice Address - Country:US
Practice Address - Phone:440-371-9086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X
OH4701291374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide