Healthcare Provider Details

I. General information

NPI: 1619010444
Provider Name (Legal Business Name): WILLARD JASON FIESSINGER APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 12/04/2023
Certification Date: 12/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83 WELLNESS WAY STE 101&201
BENTON KY
42025-7156
US

IV. Provider business mailing address

83 WELLNESS WAY STE 101&201
BENTON KY
42025-7156
US

V. Phone/Fax

Practice location:
  • Phone: 270-527-0045
  • Fax: 270-527-0075
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3005118
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: