Provider Demographics
NPI:1235880634
Name:MEMBRILLO, JESSICA DIANE (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:DIANE
Last Name:MEMBRILLO
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:DIANE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:606 FOREST PINE DR
Mailing Address - Street 2:
Mailing Address - City:BALL GROUND
Mailing Address - State:GA
Mailing Address - Zip Code:30107-5196
Mailing Address - Country:US
Mailing Address - Phone:770-608-4407
Mailing Address - Fax:
Practice Address - Street 1:145 RIVERSTONE TER STE 101
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-5327
Practice Address - Country:US
Practice Address - Phone:770-450-4807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-17
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN259993363L00000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner