Provider Demographics
NPI:1588308746
Name:NIVISON, JESSICA LEIGH (CNM)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEIGH
Last Name:NIVISON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:499 FARMINGTON AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1933
Mailing Address - Country:US
Mailing Address - Phone:860-676-8111
Mailing Address - Fax:
Practice Address - Street 1:499 FARMINGTON AVE STE 220
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1933
Practice Address - Country:US
Practice Address - Phone:860-676-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT16.000511176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT16.000511OtherCT CNM LICENSE