Healthcare Provider Details

I. General information

NPI: 1649407040
Provider Name (Legal Business Name): JESSE HENRY FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2009
Last Update Date: 07/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1252 N 22ND ST UNIT B
LARAMIE WY
82072-5306
US

IV. Provider business mailing address

1252 N 22ND ST UNIT B
LARAMIE WY
82072-5306
US

V. Phone/Fax

Practice location:
  • Phone: 307-745-3704
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number23263.1005
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: