Provider Demographics
NPI:1770295107
Name:FISHER, JESSICA (LPN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:FISHER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1134 PINE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:LINDSIDE
Mailing Address - State:WV
Mailing Address - Zip Code:24951-7022
Mailing Address - Country:US
Mailing Address - Phone:304-994-1046
Mailing Address - Fax:
Practice Address - Street 1:5414 BALLARD RED SULPHUR PKWY
Practice Address - Street 2:
Practice Address - City:PETERSTOWN
Practice Address - State:WV
Practice Address - Zip Code:24963-6048
Practice Address - Country:US
Practice Address - Phone:304-753-4322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-16
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV31580164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse