Provider Demographics
NPI:1093789000
Name:GACKLE, ELAINE MARIE (NP)
Entity Type:Individual
Prefix:MS
First Name:ELAINE
Middle Name:MARIE
Last Name:GACKLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:23021 JENSEN CT
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5579
Mailing Address - Country:US
Mailing Address - Phone:909-783-7933
Mailing Address - Fax:909-783-7933
Practice Address - Street 1:742 W HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92405-3839
Practice Address - Country:US
Practice Address - Phone:909-213-0001
Practice Address - Fax:909-386-1882
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CANP376074363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARNP376074OtherLICENSE
CARNP376074OtherLICENSE