Provider Demographics
NPI:1528595675
Name:HIESTER, JENNIPHER SHARON (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIPHER
Middle Name:SHARON
Last Name:HIESTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8340 BANDFORD WAY STE 1
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-2755
Mailing Address - Country:US
Mailing Address - Phone:919-845-3332
Mailing Address - Fax:
Practice Address - Street 1:8340 BANDFORD WAY STE 1
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-2755
Practice Address - Country:US
Practice Address - Phone:919-845-3332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-19
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-09847363A00000X
CT3830363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical