MEDICARE: MRS. JESSICA ARBETH MADDOX VANN APN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LG0600X	Gerontology Nurse Practitioner	SP008840	PA
2	363LG0600X	Gerontology Nurse Practitioner	26NJ00325000	NJ

General Provider Information

NPI Number	:	1710037163
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JESSICA ARBETH MADDOX VANN APN

Provider Business Mailing Address
First Line	:	106 LUPINE LN
Second Line	:
City	:	PENNS GROVE
State	:	NJ
Zip	:	08069-2241
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	106 LUPINE LN
Second Line	:
City	:	PENNS GROVE
State	:	NJ
Zip	:	08069-2241
Country	:	US
Telephone Number	:	609-617-5229
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/10/2007
Last Update Date	:	10/30/2011

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