Provider Demographics
NPI:1164952412
Name:MOSCHNER, JESSICA KEELY (CNP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:KEELY
Last Name:MOSCHNER
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 CARTER ST
Mailing Address - Street 2:
Mailing Address - City:BERRYVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72616-4303
Mailing Address - Country:US
Mailing Address - Phone:870-423-6661
Mailing Address - Fax:
Practice Address - Street 1:207 CARTER ST
Practice Address - Street 2:
Practice Address - City:BERRYVILLE
Practice Address - State:AR
Practice Address - Zip Code:72616-4303
Practice Address - Country:US
Practice Address - Phone:870-423-6661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007025317163W00000X
ARA005277363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARPENDINGOtherMEDICARE
ARPENDINGMedicaid
MO420045434Medicaid
MOPENDINGOtherMEDICARE