Provider Demographics
NPI:1831522150
Name:ADDISON, JENNY ANNE (RN, MSN, FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:JENNY
Middle Name:ANNE
Last Name:ADDISON
Suffix:
Gender:F
Credentials:RN, MSN, FNP-BC
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:ANNE
Other - Last Name:REILLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5986 HOLLOW WOOD CT
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-3771
Mailing Address - Country:US
Mailing Address - Phone:336-972-3830
Mailing Address - Fax:
Practice Address - Street 1:11635 N MAIN ST
Practice Address - Street 2:SUITE E
Practice Address - City:ARCHDALE
Practice Address - State:NC
Practice Address - Zip Code:27263-3270
Practice Address - Country:US
Practice Address - Phone:336-861-4110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-11
Last Update Date:2013-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC222777363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily