Provider Demographics
NPI:1902929466
Name:GARDNER, CUBBY L (FNP-C)
Entity Type:Individual
Prefix:MR
First Name:CUBBY
Middle Name:L
Last Name:GARDNER
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 SWEENEY BLVD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23665-2206
Mailing Address - Country:US
Mailing Address - Phone:940-231-3476
Mailing Address - Fax:757-224-9815
Practice Address - Street 1:74 NEALY AVE
Practice Address - Street 2:
Practice Address - City:LANGLEY AFB
Practice Address - State:VA
Practice Address - Zip Code:23665-2020
Practice Address - Country:US
Practice Address - Phone:940-349-2917
Practice Address - Fax:757-225-2788
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2010-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX618132363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily