Healthcare Provider Details

I. General information

NPI: 1447948070
Provider Name (Legal Business Name): JESSICA M ETIENNE FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2023
Last Update Date: 05/01/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 N HARRIS ST
ATHENS GA
30601-2411
US

IV. Provider business mailing address

PO BOX 1150
MONROE GA
30655-1150
US

V. Phone/Fax

Practice location:
  • Phone: 706-389-6921
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN297806
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN297806
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: