Provider Demographics
NPI:1285963827
Name:WEBSTER MEDALIS, JESSICA AUDREY (CRNA)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:AUDREY
Last Name:WEBSTER MEDALIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:AUDREY
Other - Last Name:WEBSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:5401 OLD COURT RD
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-5103
Mailing Address - Country:US
Mailing Address - Phone:410-701-4547
Mailing Address - Fax:410-701-4342
Practice Address - Street 1:5401 OLD COURT RD
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-5103
Practice Address - Country:US
Practice Address - Phone:410-701-4547
Practice Address - Fax:410-701-4342
Is Sole Proprietor?:No
Enumeration Date:2009-12-10
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR157735367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered