Basic Information
| Provider Information | |||||||||
| NPI: | 1164781696 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEYER | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 WYOMING ST | ||||||||
| Address2: | |||||||||
| City: | LANDER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825203919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073322185 | ||||||||
| FaxNumber: | 3073327799 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 WYOMING ST | ||||||||
| Address2: | |||||||||
| City: | LANDER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825203919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073322185 | ||||||||
| FaxNumber: | 3073327799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2012 | ||||||||
| LastUpdateDate: | 02/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 2012002532 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 154940001 | 01 | MO | MEDICARE PTAN | OTHER |