Provider Demographics
NPI:1164781696
Name:MEYER, JACQUELINE A (FNP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:A
Last Name:MEYER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 WYOMING ST
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3919
Mailing Address - Country:US
Mailing Address - Phone:307-332-2185
Mailing Address - Fax:307-332-7799
Practice Address - Street 1:115 WYOMING ST
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3919
Practice Address - Country:US
Practice Address - Phone:307-332-2185
Practice Address - Fax:307-332-7799
Is Sole Proprietor?:No
Enumeration Date:2012-05-03
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012002532363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO154940001OtherMEDICARE PTAN