Healthcare Provider Details

I. General information

NPI: 1790431740
Provider Name (Legal Business Name): JESSICA NUESTRO REPOLDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA DUMAGO NUESTRO FNP-C

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 03/13/2022
Certification Date: 03/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5663 E GRANT RD
TUCSON AZ
85712-2211
US

IV. Provider business mailing address

5663 E GRANT RD
TUCSON AZ
85712-2211
US

V. Phone/Fax

Practice location:
  • Phone: 520-433-4964
  • Fax:
Mailing address:
  • Phone: 520-433-4964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number270113
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: