Provider Demographics
NPI:1073667556
Name:GARNER, JACQUELINE RANAE (CNP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:RANAE
Last Name:GARNER
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 PINE ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-1669
Mailing Address - Country:US
Mailing Address - Phone:605-721-8939
Mailing Address - Fax:605-721-8853
Practice Address - Street 1:640 FLORMANN ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701
Practice Address - Country:US
Practice Address - Phone:605-718-3300
Practice Address - Fax:605-718-3426
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP000393363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDR020206OtherLICENSE
SDR020206OtherLICENSE
Q10779Medicare UPIN