Healthcare Provider Details

I. General information

NPI: 1063769826
Provider Name (Legal Business Name): JESSICA LYNNE QUESENBERRY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2012
Last Update Date: 08/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2355 DERR RD
SPRINGFIELD OH
45503-2439
US

IV. Provider business mailing address

2355 DERR RD STE A
SPRINGFIELD OH
45503-2439
US

V. Phone/Fax

Practice location:
  • Phone: 937-629-0100
  • Fax:
Mailing address:
  • Phone: 937-629-0100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number353847
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.024882
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: