Provider Demographics
NPI:1548352479
Name:GARDNER, LESLIE (CNM, APN)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:CNM, APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2018 W BRADLEY PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-4908
Mailing Address - Country:US
Mailing Address - Phone:773-244-0509
Mailing Address - Fax:773-244-0510
Practice Address - Street 1:2418 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2940
Practice Address - Country:US
Practice Address - Phone:312-666-3494
Practice Address - Fax:312-666-6228
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209002127363LX0001X
IL209-002127367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology