Healthcare Provider Details

I. General information

NPI: 1174183248
Provider Name (Legal Business Name): JENNIFER EILEEN WELLS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 06/11/2020
Certification Date: 06/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31180 ROAD 72
VISALIA CA
93291-9672
US

IV. Provider business mailing address

31180 ROAD 72
VISALIA CA
93291-9672
US

V. Phone/Fax

Practice location:
  • Phone: 877-960-3426
  • Fax:
Mailing address:
  • Phone: 877-960-3426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF06190949
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95014250
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: