Provider Demographics
NPI:1093123432
Name:FESS, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:FESS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2365 DONARSKI CT
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54302-4329
Mailing Address - Country:US
Mailing Address - Phone:920-621-1953
Mailing Address - Fax:
Practice Address - Street 1:5841 S MARYLAND AVE # MC2050
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1443
Practice Address - Country:US
Practice Address - Phone:773-702-5200
Practice Address - Fax:773-702-5160
Is Sole Proprietor?:No
Enumeration Date:2014-07-29
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.005093363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant