Healthcare Provider Details

I. General information

NPI: 1700564325
Provider Name (Legal Business Name): JESSICA ANNE WAHBY FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2023
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22250 PROVIDENCE DR STE 406
SOUTHFIELD MI
48075-6212
US

IV. Provider business mailing address

20058 BANNISTER DR
MACOMB MI
48044-5942
US

V. Phone/Fax

Practice location:
  • Phone: 248-557-9010
  • Fax:
Mailing address:
  • Phone: 586-265-9964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704334199
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: