1316626005 NPI number — JESSICA ROSE BRISTER NP, RN, APN

Table of content: JESSICA ROSE BRISTER NP, RN, APN (NPI 1316626005)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316626005 NPI number — JESSICA ROSE BRISTER NP, RN, APN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRISTER
Provider First Name:
JESSICA
Provider Middle Name:
ROSE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP, RN, APN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STAMBELU
Provider Other First Name:
JESSICA
Provider Other Middle Name:
ROSE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1316626005
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3459 CLAREMONT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT PLEASANT
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29466-9341
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-238-4747
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
86 JONATHAN LUCAS ST HOLLINGS CANCER CENTER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29425-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-792-9300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/12/2023

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: 363LF0000X , with the licence number:  350634 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 27913 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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