Provider Demographics
NPI:1023444338
Name:KIOUS-FRY, JESSICA (ANP)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:KIOUS-FRY
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11200 GOVERNOR MANLY WAY STE 303A
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-7375
Mailing Address - Country:US
Mailing Address - Phone:919-570-7590
Mailing Address - Fax:919-570-7636
Practice Address - Street 1:11200 GOVERNOR MANLY WAY STE 303A
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-7375
Practice Address - Country:US
Practice Address - Phone:919-570-7590
Practice Address - Fax:919-570-7636
Is Sole Proprietor?:No
Enumeration Date:2013-09-18
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000017662364SA2200X
NC5008281363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health