Provider Demographics
NPI:1538649868
Name:GARDNER, WILDA DEAN
Entity type:Individual
Prefix:
First Name:WILDA
Middle Name:DEAN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 385
Mailing Address - Street 2:
Mailing Address - City:CENTER
Mailing Address - State:TX
Mailing Address - Zip Code:75935-0385
Mailing Address - Country:US
Mailing Address - Phone:936-598-8963
Mailing Address - Fax:
Practice Address - Street 1:704 S GARRETT ST
Practice Address - Street 2:
Practice Address - City:CENTER
Practice Address - State:TX
Practice Address - Zip Code:75935-4150
Practice Address - Country:US
Practice Address - Phone:936-598-8963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant