Provider Demographics
NPI:1568879377
Name:FAVILLA, JENNIFER (FNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:FAVILLA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 20970
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82003-7020
Mailing Address - Country:US
Mailing Address - Phone:307-996-4777
Mailing Address - Fax:
Practice Address - Street 1:800 E 20TH ST STE 300
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3882
Practice Address - Country:US
Practice Address - Phone:307-633-7444
Practice Address - Fax:307-996-1595
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-14
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY34857.1326363LF0000X
WY24857.1326363LF0000X
WY1326363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily