1326344854 NPI number — JESSICA LEIGH CROSS FNP-BC

Table of content: JESSICA LEIGH CROSS FNP-BC (NPI 1326344854)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326344854 NPI number — JESSICA LEIGH CROSS FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CROSS
Provider First Name:
JESSICA
Provider Middle Name:
LEIGH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILLIAMS
Provider Other First Name:
JESSICA
Provider Other Middle Name:
P
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP-BC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1326344854
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RED RIVER
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87558-0010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-754-6330
Provider Business Mailing Address Fax Number:
575-222-1292

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 PIONEER ROAD
Provider Second Line Business Practice Location Address:
ST A
Provider Business Practice Location Address City Name:
RED RIVER
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87558-0010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-754-6330
Provider Business Practice Location Address Fax Number:
575-754-7168
Provider Enumeration Date:
01/31/2011

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:  CNP-01822 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: 712751 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 39532054 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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