Provider Demographics
NPI:1730795618
Name:GARDNER BURNSIDE, JELYN LANEER (STNA)
Entity type:Individual
Prefix:
First Name:JELYN
Middle Name:LANEER
Last Name:GARDNER BURNSIDE
Suffix:
Gender:M
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2036 WILMICH DR
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44319-1230
Mailing Address - Country:US
Mailing Address - Phone:330-958-6611
Mailing Address - Fax:
Practice Address - Street 1:2036 WILMICH DR
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44319-1230
Practice Address - Country:US
Practice Address - Phone:330-958-6611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH402266400620374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide