Provider Demographics
NPI:1326358557
Name:BAUER, JACLYN DIANE (ARNP)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:DIANE
Last Name:BAUER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7301 E FRONTAGE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MERRIAM
Mailing Address - State:KS
Mailing Address - Zip Code:66204-1668
Mailing Address - Country:US
Mailing Address - Phone:913-384-4040
Mailing Address - Fax:913-384-4093
Practice Address - Street 1:7301 E FRONTAGE RD STE 100
Practice Address - Street 2:
Practice Address - City:MERRIAM
Practice Address - State:KS
Practice Address - Zip Code:66204-1668
Practice Address - Country:US
Practice Address - Phone:913-384-4040
Practice Address - Fax:913-384-4093
Is Sole Proprietor?:No
Enumeration Date:2010-10-21
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-75221-041363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner