Healthcare Provider Details

I. General information

NPI: 1386827780
Provider Name (Legal Business Name): JENNIFER ELLEN CUNNINGHAM APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2007
Last Update Date: 05/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 SUMMIT AVE FAIN BUILDING 3RD FLOOR
PROVIDENCE RI
02906-2853
US

IV. Provider business mailing address

164 SUMMIT AVE FAIN BUILDING 3RD FLOOR
PROVIDENCE RI
02906-2853
US

V. Phone/Fax

Practice location:
  • Phone: 401-793-2920
  • Fax: 401-793-2859
Mailing address:
  • Phone: 401-793-2920
  • Fax: 401-793-2859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number003658
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberNPP37511
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: