Healthcare Provider Details

I. General information

NPI: 1508396755
Provider Name (Legal Business Name): JESSICA FUENTES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2017
Last Update Date: 06/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 POPLAR RD
NEWNAN GA
30265-1618
US

IV. Provider business mailing address

1505 16TH AVE
COLUMBUS GA
31901-2083
US

V. Phone/Fax

Practice location:
  • Phone: 770-400-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF06170504
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: