Provider Demographics
NPI:1992514913
Name:GARDNER, TATUM MICHELLE (ARNP)
Entity type:Individual
Prefix:
First Name:TATUM
Middle Name:MICHELLE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20903 88TH PL W
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-6905
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19110 BOTHELL WAY NE STE 201
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-2970
Practice Address - Country:US
Practice Address - Phone:253-651-4709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-03
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61414677363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner