Provider Demographics
NPI:1790022275
Name:NYSTROM, JESSICA (FNP-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:WEINTRAUB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:16222 N 59TH AVE
Mailing Address - Street 2:SUITE A100
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-1705
Mailing Address - Country:US
Mailing Address - Phone:623-334-4000
Mailing Address - Fax:623-334-4400
Practice Address - Street 1:16222 N 59TH AVE
Practice Address - Street 2:SUITE A100
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-1705
Practice Address - Country:US
Practice Address - Phone:623-334-4000
Practice Address - Fax:623-334-4400
Is Sole Proprietor?:No
Enumeration Date:2013-01-03
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP4771363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily