Provider Demographics
NPI:1063111391
Name:DE LA GARZA, JACQUELINE LYNETTE (FNP-C)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LYNETTE
Last Name:DE LA GARZA
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:GENERAL DELIVERY
Mailing Address - Street 2:
Mailing Address - City:VOLCANO
Mailing Address - State:HI
Mailing Address - Zip Code:96785-9999
Mailing Address - Country:US
Mailing Address - Phone:808-430-0654
Mailing Address - Fax:
Practice Address - Street 1:67-1123 MAMALAHOA HWY STE 120124
Practice Address - Street 2:
Practice Address - City:KAMUELA
Practice Address - State:HI
Practice Address - Zip Code:96743-8451
Practice Address - Country:US
Practice Address - Phone:808-881-4710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRN-106817163W00000X
HIAPRN-3777363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIRN-106817OtherHI RN LICENSURE
HIAPRN-3777OtherAPRN LICENSURE