Provider Demographics
NPI:1811605744
Name:GARDNER, KATRINA LAVERNE (INDEPENDANT PROVIDER)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:LAVERNE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:INDEPENDANT PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 RUTH ELLEN DR APT H311
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44143-1028
Mailing Address - Country:US
Mailing Address - Phone:216-240-7216
Mailing Address - Fax:216-472-8530
Practice Address - Street 1:120 RUTH ELLEN DR APT H311
Practice Address - Street 2:
Practice Address - City:RICHMOND HTS
Practice Address - State:OH
Practice Address - Zip Code:44143-1028
Practice Address - Country:US
Practice Address - Phone:216-240-7216
Practice Address - Fax:216-472-8530
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1831901253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care