Provider Demographics
NPI:1770099319
Name:SPRAGUE, JILLIAN HERNANDEZ (CPNP)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:HERNANDEZ
Last Name:SPRAGUE
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2406 BLUE RIDGE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6692
Mailing Address - Country:US
Mailing Address - Phone:919-786-5001
Mailing Address - Fax:919-786-5051
Practice Address - Street 1:501 W 14TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19801-1013
Practice Address - Country:US
Practice Address - Phone:302-428-4410
Practice Address - Fax:302-428-4078
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-19
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DELJ-0010479363LP0200X, 363L00000X
NC5011666363LP0200X
NC310313163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse