Basic Information
| Provider Information | |||||||||
| NPI: | 1710540950 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FISHER | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 45567 SHOAL DR | ||||||||
| Address2: | |||||||||
| City: | MACOMB | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480444239 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11885 E 12 MILE RD | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480933474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865761615 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2019 | ||||||||
| LastUpdateDate: | 02/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704302723 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.