Basic Information
| Provider Information | |||||||||
| NPI: | 1750386405 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LARDIE | ||||||||
| FirstName: | JACQUELYN | ||||||||
| MiddleName: | LOUISE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 612 N. MAPLE STREET | ||||||||
| Address2: | |||||||||
| City: | CARLSBAD | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5756280927 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2420 W. PIERCE ST | ||||||||
| Address2: | STE. 103 | ||||||||
| City: | CARLSBAD | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5756285051 | ||||||||
| FaxNumber: | 5756280493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2005 | ||||||||
| LastUpdateDate: | 03/04/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 4704242886 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | CNP-01544 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 01500759 | 05 | NM | MEDICAID |