Healthcare Provider Details

I. General information

NPI: 1609747864
Provider Name (Legal Business Name): JESSICA RAE LYNN CONWAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JESSICA RAE LYNN FLORES

II. Dates (important events)

Enumeration Date: 09/12/2025
Last Update Date: 09/12/2025
Certification Date: 09/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5828 JAMES DRIVE W
WEST FARGO ND
58078
US

IV. Provider business mailing address

5828 JAMES DRIVE W
WEST FARGO ND
58078
US

V. Phone/Fax

Practice location:
  • Phone: 701-715-0926
  • Fax:
Mailing address:
  • Phone: 701-715-0926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number$$$$$$$$$
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: