Provider Demographics
NPI:1104167477
Name:FIERRO, JILL (FNP)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:FIERRO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2402 W PIERCE ST
Mailing Address - Street 2:STE 4A
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-3537
Mailing Address - Country:US
Mailing Address - Phone:575-234-9964
Mailing Address - Fax:
Practice Address - Street 1:2402 W PIERCE ST
Practice Address - Street 2:STE 4A
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-3537
Practice Address - Country:US
Practice Address - Phone:575-234-9964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP02149363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000T9592Medicaid
NM000T9592Medicaid