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NPI Code Detail

MEDICARE: MS. ELAINE MARIE GACKLE NP

MEDICARE: MS. ELAINE MARIE GACKLE 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
1363LF0000XFamily Nurse PractitionerNP376074CA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1RNP376074OTHERCALICENSE

General Provider Information

NPI Number : 1093789000
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. ELAINE MARIE GACKLE NP
Provider Business Mailing Address
First Line : 23021 JENSEN CT
Second Line :
City : GRAND TERRACE
State : CA
Zip : 92313-5579
Country : US
Telephone Number : 909-783-7933
Fax Number : 909-783-7933
Provider Business Practice Location Address
First Line : 742 W HIGHLAND AVE
Second Line :
City : SAN BERNARDINO
State : CA
Zip : 92405-3839
Country : US
Telephone Number : 909-213-0001
Fax Number : 909-386-1882
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/15/2006
Last Update Date : 10/03/2011

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