Basic Information
Provider Information | |||||||||
NPI: | 1790098127 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | REASNER | ||||||||
FirstName: | MICHELLE | ||||||||
MiddleName: | GARDNER | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 401 E. CYPRESS AVE | ||||||||
Address2: |   | ||||||||
City: | LOMPOC | ||||||||
State: | CA | ||||||||
PostalCode: | 934364519 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8058651940 | ||||||||
FaxNumber: | 8058651954 | ||||||||
Practice Location | |||||||||
Address1: | 401 E CYPRESS AVE | ||||||||
Address2: |   | ||||||||
City: | LOMPOC | ||||||||
State: | CA | ||||||||
PostalCode: | 934366806 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8058651940 | ||||||||
FaxNumber: | 8058651954 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/14/2010 | ||||||||
LastUpdateDate: | 05/07/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 558140 | CA | Y |   | Nursing Service Providers | Registered Nurse |   |
No ID Information.