Provider Demographics
NPI:1891920567
Name:GARDNER, JACQUELINE (FNP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 2 BOX 6074
Mailing Address - Street 2:
Mailing Address - City:KEAAU
Mailing Address - State:HI
Mailing Address - Zip Code:96749-8300
Mailing Address - Country:US
Mailing Address - Phone:808-982-7809
Mailing Address - Fax:
Practice Address - Street 1:45 MOHOULI ST
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-7210
Practice Address - Country:US
Practice Address - Phone:808-896-5569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-23
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAMD 59363AM0700X
HIAPRN 17363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical