Healthcare Provider Details

I. General information

NPI: 1972257525
Provider Name (Legal Business Name): JESSICA BALLESTEROS-HOLMES CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2022
Last Update Date: 02/11/2022
Certification Date: 02/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10492 BRISTOW CENTER DR
BRISTOW VA
20136-2202
US

IV. Provider business mailing address

3011 WILLIAMS STATION RD
MATTHEWS NC
28105-1233
US

V. Phone/Fax

Practice location:
  • Phone: 571-379-4246
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberBALL-37H6G
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: