Provider Demographics
NPI:1851170716
Name:DISMANG, JESSICA RAYANN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RAYANN
Last Name:DISMANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:RAYANN
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 205
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62827-0205
Mailing Address - Country:US
Mailing Address - Phone:618-380-1452
Mailing Address - Fax:
Practice Address - Street 1:315 N ALLEN ST APT 2
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62827-2284
Practice Address - Country:US
Practice Address - Phone:618-380-1452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-28
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider