Basic Information
| Provider Information | |||||||||
| NPI: | 1568048445 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIDERMAN | ||||||||
| FirstName: | JESSIKA | ||||||||
| MiddleName: | HELENA | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6912 S QUENTIN ST STE 50 | ||||||||
| Address2: | |||||||||
| City: | CENTENNIAL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801124531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7202822377 | ||||||||
| FaxNumber: | 8773025251 | ||||||||
| Practice Location | |||||||||
| Address1: | 6500 S DIXIE HWY | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334054416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2395335770 | ||||||||
| FaxNumber: | 8444650864 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2021 | ||||||||
| LastUpdateDate: | 11/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 347118 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | APRN11012513 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.