MEDICARE: JESSICA NICOLE CUNNINGHAM RWP

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	133N00000X	Nutritionist

General Provider Information

NPI Number	:	1407603574
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA NICOLE CUNNINGHAM RWP

Provider Business Mailing Address
First Line	:	11135 SHADOW WOODS LN
Second Line	:
City	:	WHITMORE LAKE
State	:	MI
Zip	:	48189-9121
Country	:	US
Telephone Number	:	614-668-5881
Fax Number	:

Provider Business Practice Location Address
First Line	:	11135 SHADOW WOODS LN
Second Line	:
City	:	WHITMORE LAKE
State	:	MI
Zip	:	48189-9121
Country	:	US
Telephone Number	:	614-668-5881
Fax Number	:

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

Provider Enumeration Date	:	05/06/2024
Last Update Date	:	05/06/2024

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