Basic Information
| Provider Information | |||||||||
| NPI: | 1093950115 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAMPLE | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | BROOKE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | RN, CPNP-PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7777 FOREST LN STE B | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752302571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725667730 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7777 FOREST LN STE B246 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752306816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724545288 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2008 | ||||||||
| LastUpdateDate: | 04/29/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 689425 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.