Basic Information
| Provider Information | |||||||||
| NPI: | 1376106633 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAUZE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROBERTSON | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | DEPT. 453 PO BOX 1000 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381480001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285752625 | ||||||||
| FaxNumber: | 8283502174 | ||||||||
| Practice Location | |||||||||
| Address1: | 1606 US HIGHWAY 27 N | ||||||||
| Address2: | |||||||||
| City: | CYNTHIANA | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410313718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592348852 | ||||||||
| FaxNumber: | 8592348859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2019 | ||||||||
| LastUpdateDate: | 05/03/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 3013223 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | K299882 | 01 | KY | MEDICARE PTAN | OTHER | K299883 | 01 | KY | MEDICARE PTAN | OTHER | 7100593140 | 05 | KY | MEDICAID | 0471581 | 05 | OH | MEDICAID |