Healthcare Provider Details

I. General information

NPI: 1285115162
Provider Name (Legal Business Name): JESSICA NICOLE ANDRINA CPNP-AC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA NICOLE CONLEY

II. Dates (important events)

Enumeration Date: 08/28/2018
Last Update Date: 09/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BARCLAY AVE NE STE 202
GRAND RAPIDS MI
49503-2525
US

IV. Provider business mailing address

1668 SOUTHPOINTE TRL
OTSEGO MI
49078-9323
US

V. Phone/Fax

Practice location:
  • Phone: 616-458-1722
  • Fax:
Mailing address:
  • Phone: 269-267-6732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704273953
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number4704273953
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: