Provider Demographics
NPI:1821148206
Name:LEIKER-WORTERS, JACQUALYNE ROSE (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:JACQUALYNE
Middle Name:ROSE
Last Name:LEIKER-WORTERS
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 1:3762 WOODS WALK BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-2362
Mailing Address - Country:US
Mailing Address - Phone:561-434-0503
Mailing Address - Fax:
Practice Address - Street 1:12989 SOUTHERN BLVD
Practice Address - Street 2:103
Practice Address - City:LOXAHATCHEE
Practice Address - State:FL
Practice Address - Zip Code:33470-9211
Practice Address - Country:US
Practice Address - Phone:561-784-0473
Practice Address - Fax:561-784-9038
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2875912363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE8252Medicare ID - Type Unspecified
FLP69325Medicare UPIN