Provider Demographics
NPI:1992465249
Name:REDDELL, JACQUELINE MINARD (LVN)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MINARD
Last Name:REDDELL
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:MINARD
Other - Last Name:BANNISTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LVN
Mailing Address - Street 1:10703 RR 12
Mailing Address - Street 2:
Mailing Address - City:WIMBERLEY
Mailing Address - State:TX
Mailing Address - Zip Code:78676-5239
Mailing Address - Country:US
Mailing Address - Phone:737-268-5610
Mailing Address - Fax:512-690-0171
Practice Address - Street 1:10703 RR 12
Practice Address - Street 2:
Practice Address - City:WIMBERLEY
Practice Address - State:TX
Practice Address - Zip Code:78676-5239
Practice Address - Country:US
Practice Address - Phone:737-268-5610
Practice Address - Fax:512-690-0171
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-28
Last Update Date:2022-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX211850164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse