Provider Demographics
NPI:1598538225
Name:FITTS, JESSICA NICOLE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:FITTS
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:PO BOX 361095
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32936-1095
Mailing Address - Country:US
Mailing Address - Phone:321-622-8730
Mailing Address - Fax:
Practice Address - Street 1:1301 W EAU GALLIE BLVD STE 108
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-5390
Practice Address - Country:US
Practice Address - Phone:321-622-8730
Practice Address - Fax:321-622-8732
Is Sole Proprietor?:No
Enumeration Date:2023-11-03
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9117976363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant