Provider Demographics
NPI:1134635469
Name:GARDNER, JAQUITA Y (APRN)
Entity Type:Individual
Prefix:
First Name:JAQUITA
Middle Name:Y
Last Name:GARDNER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10901 E 48TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-5830
Mailing Address - Country:US
Mailing Address - Phone:918-749-8765
Mailing Address - Fax:918-392-2155
Practice Address - Street 1:10901 E 48TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-5830
Practice Address - Country:US
Practice Address - Phone:918-749-8765
Practice Address - Fax:918-392-2155
Is Sole Proprietor?:No
Enumeration Date:2017-12-22
Last Update Date:2017-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0080870364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health