Provider Demographics
NPI:1306300405
Name:MAYFIELD, JESSICA (APRN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MAYFIELD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10630 INGRAM ST
Mailing Address - Street 2:
Mailing Address - City:BROWNSBORO
Mailing Address - State:TX
Mailing Address - Zip Code:75756-6635
Mailing Address - Country:US
Mailing Address - Phone:903-805-4211
Mailing Address - Fax:
Practice Address - Street 1:2147 NE COACHMAN RD
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33765-2616
Practice Address - Country:US
Practice Address - Phone:727-466-0078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11000546363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily