Provider Demographics
NPI:1750399267
Name:JESSEE, CYNTHIA (CPNP)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:JESSEE
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 BEECH ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GATE CITY
Mailing Address - State:VA
Mailing Address - Zip Code:24251-3623
Mailing Address - Country:US
Mailing Address - Phone:276-386-1312
Mailing Address - Fax:276-386-2116
Practice Address - Street 1:190 BEECH ST
Practice Address - Street 2:SUITE 102
Practice Address - City:GATE CITY
Practice Address - State:VA
Practice Address - Zip Code:24251-3623
Practice Address - Country:US
Practice Address - Phone:276-386-1312
Practice Address - Fax:276-386-2116
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA002416575363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010162203Medicaid
VA010162203Medicaid