Basic Information
| Provider Information | |||||||||
| NPI: | 1093137226 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FITZWATER | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CAMPBELL | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 186 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | GRANTSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261477100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043549244 | ||||||||
| FaxNumber: | 3043549323 | ||||||||
| Practice Location | |||||||||
| Address1: | 186 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | GRANTSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261477100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043549244 | ||||||||
| FaxNumber: | 3043549323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2014 | ||||||||
| LastUpdateDate: | 02/12/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 75755 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 75755 | 01 | WV | LICENSE NUMBER | OTHER |