Provider Demographics
NPI:1861941023
Name:GARDNER, ERIN
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:
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 727
Mailing Address - Street 2:
Mailing Address - City:CUTCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11935-0727
Mailing Address - Country:US
Mailing Address - Phone:917-754-6065
Mailing Address - Fax:
Practice Address - Street 1:4115 STILLWATER AVE
Practice Address - Street 2:
Practice Address - City:CUTCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11935-2449
Practice Address - Country:US
Practice Address - Phone:917-754-6065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-29
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY505726-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY505726-1OtherNY STATE EDUCATION DEPARTMENT