MEDICARE: JESSICA JUNE MOFFETT BSN, RN

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	163W00000X	Registered Nurse	RN155838	AZ

General Provider Information

NPI Number	:	1578114815
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA JUNE MOFFETT BSN, RN

Provider Business Mailing Address
First Line	:	1575 W SOUTHERN AVE
Second Line	:
City	:	APACHE JUNCTION
State	:	AZ
Zip	:	85120-7456
Country	:	US
Telephone Number	:	480-982-1110
Fax Number	:

Provider Business Practice Location Address
First Line	:	1575 W SOUTHERN AVE
Second Line	:
City	:	APACHE JUNCTION
State	:	AZ
Zip	:	85120-7456
Country	:	US
Telephone Number	:	480-982-1110
Fax Number	:

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

Provider Enumeration Date	:	09/27/2019
Last Update Date	:	09/27/2019

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