Provider Demographics
NPI:1750386405
Name:LARDIE, JACQUELYN LOUISE (NP)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:LOUISE
Last Name:LARDIE
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 1:612 N. MAPLE STREET
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220
Mailing Address - Country:US
Mailing Address - Phone:575-628-0927
Mailing Address - Fax:
Practice Address - Street 1:2420 W. PIERCE ST
Practice Address - Street 2:STE. 103
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220
Practice Address - Country:US
Practice Address - Phone:575-628-5051
Practice Address - Fax:575-628-0493
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-19
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704242886363LF0000X
NMCNP-01544363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM01500759Medicaid
MIM95020007Medicare ID - Type Unspecified
NMNM302333Medicare PIN
NM01500759Medicaid