Basic Information
| Provider Information | |||||||||
| NPI: | 1033711304 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARDINER | ||||||||
| FirstName: | LEA | ||||||||
| MiddleName: | |||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 KESSEL CT STE 105 | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537116227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082802700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 702 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082802617 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2020 | ||||||||
| LastUpdateDate: | 11/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WA0400X | 238523 | WI | N | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) | 163WP0808X | 238523 | WI | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.