Provider Demographics
NPI:1912715608
Name:GARDNER, MERVEL DELORES
Entity type:Individual
Prefix:MISS
First Name:MERVEL
Middle Name:DELORES
Last Name:GARDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MERVEL
Other - Middle Name:DELORES
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SALMON-REID
Mailing Address - Street 1:4200 6TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-1042
Mailing Address - Country:US
Mailing Address - Phone:360-459-8311
Mailing Address - Fax:
Practice Address - Street 1:4200 6TH AVE SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1042
Practice Address - Country:US
Practice Address - Phone:360-459-8311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-26
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9457121163WH1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH1000XNursing Service ProvidersRegistered NurseHospice