Basic Information
Provider Information | |||||||||
NPI: | 1306276837 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALKER | ||||||||
FirstName: | JACQUELINE | ||||||||
MiddleName: | GARALDE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WALKER | ||||||||
OtherFirstName: | JACQUELINE | ||||||||
OtherMiddleName: | G | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | FNP | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 9504 SUMMER CYPRESS ST | ||||||||
Address2: |   | ||||||||
City: | LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 891233930 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7025807997 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3750 S JONES BLVD STE 100 | ||||||||
Address2: |   | ||||||||
City: | LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 891032209 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7024447744 | ||||||||
FaxNumber: | 7024447898 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/19/2013 | ||||||||
LastUpdateDate: | 01/18/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WH0200X | RN73810 | NV | N |   | Nursing Service Providers | Registered Nurse | Home Health | 363L00000X | 817139 | NV | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 1702161 | 05 | NV |   | MEDICAID |