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General NPI Number Information
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NPI Number | 1992043517
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Entity Type | Individual
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Provider Name | MARY JESSICA FIESTA ANP-BC
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Gender | Female
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Dates
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Enumeration Date | 01/17/2013
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Last Update Date | 03/20/2020
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Provider Practice Location Address
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Address Line | 6301 GASTON AVE SUITE 100 WEST TOWER
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City | DALLAS
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State | TX
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Zip | 75214-3922
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Country | US
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Telephone | 214-827-3610
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Fax | 214-821-4017
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Provider Business Mailing Address
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Address Line | 906 W CANNON ST STE A
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City | FORT WORTH
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State | TX
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Zip | 76104-3031
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Country | US
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Telephone | 817-321-0951
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Fax | 817-299-0790
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | 721121
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License Number State | TX
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