Healthcare Provider Details

I. General information

NPI: 1376019208
Provider Name (Legal Business Name): JESSIE RICHIE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSIE PARDO PA-C

II. Dates (important events)

Enumeration Date: 10/18/2018
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 SE OCEAN BLVD STE 301
STUART FL
34996-3301
US

IV. Provider business mailing address

1001 WILSON BLVD APT 1101
ARLINGTON VA
22209-2261
US

V. Phone/Fax

Practice location:
  • Phone: 772-220-3339
  • Fax: 772-286-2635
Mailing address:
  • Phone: 561-389-1684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: