Provider Demographics
NPI:1790431740
Name:REPOLDA, JESSICA NUESTRO
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:NUESTRO
Last Name:REPOLDA
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:DUMAGO
Other - Last Name:NUESTRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:5663 E GRANT RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2211
Mailing Address - Country:US
Mailing Address - Phone:520-433-4964
Mailing Address - Fax:
Practice Address - Street 1:5663 E GRANT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2211
Practice Address - Country:US
Practice Address - Phone:520-433-4964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-01
Last Update Date:2022-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ270113363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner