Provider Demographics
NPI:1639781958
Name:FUENTES CAMACHO, JACQUELINE (NP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:FUENTES CAMACHO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:FUENTES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2400 S AVENUE A
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-7170
Mailing Address - Country:US
Mailing Address - Phone:928-344-2000
Mailing Address - Fax:
Practice Address - Street 1:2451 S AVENUE A STE A104
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-7189
Practice Address - Country:US
Practice Address - Phone:928-336-2165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN208944163WM0705X
AZ305501363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical