Provider Demographics
NPI:1295476653
Name:JETLEY, PATSYLYNN
Entity type:Individual
Prefix:
First Name:PATSYLYNN
Middle Name:
Last Name:JETLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PATSYLYNN
Other - Middle Name:
Other - Last Name:CEPEDA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PMB 761 BOX 10003
Mailing Address - Street 2:
Mailing Address - City:SAIPAN
Mailing Address - State:MP
Mailing Address - Zip Code:96950
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 AKARI BUILDING
Practice Address - Street 2:
Practice Address - City:SAIPAN
Practice Address - State:MP
Practice Address - Zip Code:96950
Practice Address - Country:US
Practice Address - Phone:670-233-2668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI4721183500000X
MP0111183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist