Basic Information
| Provider Information | |||||||||
| NPI: | 1700458254 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRIESZ | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | DYAN | ||||||||
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| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 OLD SOUTH RIVER RD | ||||||||
| Address2: | |||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633034120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362241210 | ||||||||
| FaxNumber: | 6369461008 | ||||||||
| Practice Location | |||||||||
| Address1: | 3531 STARDUST DR | ||||||||
| Address2: | |||||||||
| City: | HANNIBAL | ||||||||
| State: | MO | ||||||||
| PostalCode: | 634016224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736031460 | ||||||||
| FaxNumber: | 5736031462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2021 | ||||||||
| LastUpdateDate: | 07/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 043125358 | IL | N | Nursing Service Providers | Licensed Practical Nurse | 164W00000X | 2012032038 | MO | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.