Provider Demographics
NPI:1790437143
Name:DISSELL, JENNIFER (FNP-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DISSELL
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 FULLER RD
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04021-3063
Mailing Address - Country:US
Mailing Address - Phone:207-462-7360
Mailing Address - Fax:
Practice Address - Street 1:15 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-7997
Practice Address - Country:US
Practice Address - Phone:207-621-8880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-26
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP201465363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner