Healthcare Provider Details

I. General information

NPI: 1629026646
Provider Name (Legal Business Name): JENNIFER R TAPPIN-ADDISON AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER R TAPPIN-ADDISON AGNP-C

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 09/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NORTON SHORE HEALTH CORPORATION 1000 GREG KRUSCHEK AVE
NOME AK
99762
US

IV. Provider business mailing address

4600 MORNING GLORY LN
MANSFIELD TX
76063-6871
US

V. Phone/Fax

Practice location:
  • Phone: 907-443-3311
  • Fax:
Mailing address:
  • Phone: 907-443-6761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number4775-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP134042
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: