Provider Demographics
NPI:1477083996
Name:DIVANNO, JESSICA (CRNP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DIVANNO
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 JO MAR DR
Mailing Address - Street 2:
Mailing Address - City:SANDY HOOK
Mailing Address - State:CT
Mailing Address - Zip Code:06482-1210
Mailing Address - Country:US
Mailing Address - Phone:203-240-8757
Mailing Address - Fax:
Practice Address - Street 1:43 JO MAR DR
Practice Address - Street 2:
Practice Address - City:SANDY HOOK
Practice Address - State:CT
Practice Address - Zip Code:06482-1210
Practice Address - Country:US
Practice Address - Phone:203-240-8757
Practice Address - Fax:203-240-8757
Is Sole Proprietor?:No
Enumeration Date:2017-06-18
Last Update Date:2017-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP017375363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner