Basic Information
| Provider Information | |||||||||
| NPI: | 1205562329 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MASSARA | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1466 SHANKIN CT | ||||||||
| Address2: | |||||||||
| City: | WOLVERINE LAKE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483902436 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3990 JOHN R ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137458040 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2022 | ||||||||
| LastUpdateDate: | 08/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 4704304771 | MI | N | Nursing Service Providers | Registered Nurse | 367500000X | 4704304331 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.