Healthcare Provider Details

I. General information

NPI: 1720050818
Provider Name (Legal Business Name): ANGELA M JESSIE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 06/20/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 SARTIN DR
EDMONTON KY
42129-8170
US

IV. Provider business mailing address

PO BOX 1080
BURKESVILLE KY
42717-1080
US

V. Phone/Fax

Practice location:
  • Phone: 270-432-2444
  • Fax: 270-432-2445
Mailing address:
  • Phone: 270-858-6655
  • Fax: 270-858-4027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3003026
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number3003026
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: