Provider Demographics
NPI:1316581713
Name:CROSS, JACQUELINE CANDACE (REGISTERED NURSE)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:CANDACE
Last Name:CROSS
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:MS
Other - First Name:JACQUELINE
Other - Middle Name:CANDACE
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:REGISTERED NURSE
Mailing Address - Street 1:601 WASHINGTON ST APT B
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-2781
Mailing Address - Country:US
Mailing Address - Phone:301-697-9398
Mailing Address - Fax:
Practice Address - Street 1:601 WASHINGTON ST APT B
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-2781
Practice Address - Country:US
Practice Address - Phone:301-697-9398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-30
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR199149163W00000X
WV106050367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse