MEDICARE: JACQUELYN LOUISE LARDIE NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	4704242886	MI
2	363LF0000X	Family Nurse Practitioner	CNP-01544	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750386405
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELYN LOUISE LARDIE NP

Provider Business Mailing Address
First Line	:	612 N. MAPLE STREET
Second Line	:
City	:	CARLSBAD
State	:	NM
Zip	:	88220
Country	:	US
Telephone Number	:	575-628-0927
Fax Number	:

Provider Business Practice Location Address
First Line	:	2420 W. PIERCE ST
Second Line	:	STE. 103
City	:	CARLSBAD
State	:	NM
Zip	:	88220
Country	:	US
Telephone Number	:	575-628-5051
Fax Number	:	575-628-0493

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/19/2005
Last Update Date	:	03/04/2010

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