Healthcare Provider Details

I. General information

NPI: 1124054705
Provider Name (Legal Business Name): JEANINE NORIKO PACKHAM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 03/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 LOCUST ST
RENO NV
89502-2597
US

IV. Provider business mailing address

PO BOX 10584
RENO NV
89510-0584
US

V. Phone/Fax

Practice location:
  • Phone: 775-786-7200
  • Fax:
Mailing address:
  • Phone: 775-786-7200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number200150101NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: