Basic Information
| Provider Information | |||||||||
| NPI: | 1043215049 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GARDNER | ||||||||
| FirstName: | LYNNELL | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6761 E TANQUE VERDE RD | ||||||||
| Address2: | STE 6 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857155323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5202982313 | ||||||||
| FaxNumber: | 5202981554 | ||||||||
| Practice Location | |||||||||
| Address1: | 6761 E TANQUE VERDE RD | ||||||||
| Address2: | STE 6 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857155323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5202982313 | ||||||||
| FaxNumber: | 5202981554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 18444 | AZ | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 283870 | 05 | AZ | MEDICAID |