1073035820 NPI number — DR. JENESSA JOANA STILES AUD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073035820 NPI number — DR. JENESSA JOANA STILES AUD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STILES
Provider First Name:
JENESSA
Provider Middle Name:
JOANA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
AUD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073035820
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
871 BEAVER DRIVE, PO BOX 308
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUBOIS
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15801-0308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-375-0455
Provider Business Mailing Address Fax Number:
814-375-2721

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
871 BEAVER DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUBOIS
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15801-3767
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-375-0455
Provider Business Practice Location Address Fax Number:
814-375-2721
Provider Enumeration Date:
07/13/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  AT006511 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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