1689456725 NPI number — JESSICA MEGAN FELLENZER

Table of content: JESSICA MEGAN FELLENZER (NPI 1689456725)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689456725 NPI number — JESSICA MEGAN FELLENZER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FELLENZER
Provider First Name:
JESSICA
Provider Middle Name:
MEGAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1689456725
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4005 GALANTIS DR APT 203F
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOREHEAD CITY
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28557-0120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-800-4218
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5020 US HIGHWAY 70 W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOREHEAD CITY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28557-4531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-726-0555
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/13/2023

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: 183500000X , with the licence number:  32696 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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