1710987474 NPI number — DR. KIRSTEN JEANNE GARDNER M.D.

Table of content: DR. KIRSTEN JEANNE GARDNER M.D. (NPI 1710987474)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710987474 NPI number — DR. KIRSTEN JEANNE GARDNER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARDNER
Provider First Name:
KIRSTEN
Provider Middle Name:
JEANNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710987474
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/28/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1684
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIERRA MADRE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91025-4684
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
266-618-7952
Provider Business Mailing Address Fax Number:
626-270-5440

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
434 FAIRVIEW AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIERRA MADRE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91024-1032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
266-186-7952
Provider Business Practice Location Address Fax Number:
626-270-5440
Provider Enumeration Date:
07/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  A93580 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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