1063111391 NPI number — JACQUELINE LYNETTE DE LA GARZA FNP-C

Table of content: JACQUELINE LYNETTE DE LA GARZA FNP-C (NPI 1063111391)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063111391 NPI number — JACQUELINE LYNETTE DE LA GARZA FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE LA GARZA
Provider First Name:
JACQUELINE
Provider Middle Name:
LYNETTE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063111391
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
GENERAL DELIVERY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VOLCANO
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96785-9999
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-430-0654
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
67-1123 MAMALAHOA HWY STE 120124
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KAMUELA
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96743-8451
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-881-4710
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/27/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  RN-106817 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: APRN-3777 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: RN-106817 . This is a "HI RN LICENSURE" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: APRN-3777 . This is a "APRN LICENSURE" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".




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