Provider Demographics
NPI:1992043517
Name:FIESTA, MARY JESSICA (ANP-BC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JESSICA
Last Name:FIESTA
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:906 W CANNON ST
Mailing Address - Street 2:STE A
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3031
Mailing Address - Country:US
Mailing Address - Phone:817-321-0951
Mailing Address - Fax:817-299-0790
Practice Address - Street 1:6301 GASTON AVE
Practice Address - Street 2:SUITE 100 WEST TOWER
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214-3922
Practice Address - Country:US
Practice Address - Phone:214-827-3610
Practice Address - Fax:214-821-4017
Is Sole Proprietor?:No
Enumeration Date:2013-01-17
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX721121363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health