Basic Information
| Provider Information | |||||||||
| NPI: | 1992043517 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FIESTA | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | JESSICA | ||||||||
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| Credential: | ANP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 906 W CANNON ST | ||||||||
| Address2: | STE A | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761043031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173210951 | ||||||||
| FaxNumber: | 8172990790 | ||||||||
| Practice Location | |||||||||
| Address1: | 6301 GASTON AVE | ||||||||
| Address2: | SUITE 100 WEST TOWER | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752143922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148273610 | ||||||||
| FaxNumber: | 2148214017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2013 | ||||||||
| LastUpdateDate: | 03/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 721121 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.