Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | CHIR009011 | GA |
N | 111NN1001X | Nutrition | CHIR009011 | GA |
NPI | 1609479062 |
---|---|
Provider Name | Gwendolyn Tanner Gardner |
First Address | Marietta, GA 30060-2943 |
Second Address | Marietta, GA 30060-2943 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/11/2020 |
Last Update Date | 07/04/2021 |