Healthcare Provider Details

I. General information

NPI: 1124563713
Provider Name (Legal Business Name): JESSICA BROOKE WREN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2017
Last Update Date: 01/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

89 INTERCHANGE DR
RICHMOND HILL GA
31324-7661
US

IV. Provider business mailing address

PO BOX 15849
SAVANNAH GA
31416-2549
US

V. Phone/Fax

Practice location:
  • Phone: 912-527-5301
  • Fax: 912-756-4740
Mailing address:
  • Phone: 912-303-3560
  • Fax: 912-303-3506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN190747NP
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: