Basic Information
| Provider Information | |||||||||
| NPI: | 1952401093 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FISHER | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LOUISE | ||||||||
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| Credential: | RN,MS,CFNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 BRIGHAM DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PERRYSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435517114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198727700 | ||||||||
| FaxNumber: | 4198740196 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 BRIGHAM DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PERRYSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435517114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198727700 | ||||||||
| FaxNumber: | 4198740196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 04/30/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | COA.04253-NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 4704222999 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 2176292 | 05 | OH | MEDICAID | 00000055060 | 01 | ANTHEM | OTHER |