Basic Information
Provider Information | |||||||||
NPI: | 1972064558 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DE LA GARZA | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | DENISE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | ACNPC-NG | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WESLEY | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: | D | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | ACNPC-NG | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 16453 N 150TH DR | ||||||||
Address2: |   | ||||||||
City: | SURPRISE | ||||||||
State: | AZ | ||||||||
PostalCode: | 853741472 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6233132347 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 287 E HUNT HWY STE 105 | ||||||||
Address2: |   | ||||||||
City: | SAN TAN VALLEY | ||||||||
State: | AZ | ||||||||
PostalCode: | 851435096 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4806778282 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/27/2019 | ||||||||
LastUpdateDate: | 03/14/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/14/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 224060 | AZ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.