Healthcare Provider Details

I. General information

NPI: 1588856967
Provider Name (Legal Business Name): MRS. JACQUELINE KIZER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2007
Last Update Date: 02/20/2025
Certification Date: 02/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1559 WATASHEAMU RD
GARDNERVILLE NV
89460-7455
US

IV. Provider business mailing address

1559 WATASHEAMU RD
GARDNERVILLE NV
89460-7455
US

V. Phone/Fax

Practice location:
  • Phone: 775-265-4215
  • Fax: 775-265-6071
Mailing address:
  • Phone: 775-265-4215
  • Fax: 775-265-6071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number832829
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number24178
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: