Provider Demographics
NPI:1689106254
Name:NURSE, JACQUELINE ELIZABETH (NP)
Entity Type:Individual
Prefix:MISS
First Name:JACQUELINE
Middle Name:ELIZABETH
Last Name:NURSE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:652 CANYON STONE CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3978
Mailing Address - Country:US
Mailing Address - Phone:772-333-4298
Mailing Address - Fax:
Practice Address - Street 1:652 CANYON STONE CIR
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3978
Practice Address - Country:US
Practice Address - Phone:772-333-4298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-01
Last Update Date:2017-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2784612363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner