Provider Demographics
NPI:1184936627
Name:NEDOM, JESSICA SUSANA (NP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:SUSANA
Last Name:NEDOM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:SUSANA
Other - Last Name:RODRIGUEZ MUNOZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2930 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:CO
Mailing Address - Zip Code:80620-1011
Mailing Address - Country:US
Mailing Address - Phone:970-353-9403
Mailing Address - Fax:970-353-9906
Practice Address - Street 1:2930 11TH AVE
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:CO
Practice Address - Zip Code:80620-1011
Practice Address - Country:US
Practice Address - Phone:970-353-9403
Practice Address - Fax:970-353-9906
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2012-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO176219163W00000X
CO10334363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO37179870Medicaid
COA105349Medicare PIN
CO37179870Medicaid