Provider Demographics
NPI:1902997208
Name:HEALY-FETTER, JENNIFER SUE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUE
Last Name:HEALY-FETTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:SUE
Other - Last Name:HEALY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3302 BONITA BEACH RD
Mailing Address - Street 2:# 170
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-4174
Mailing Address - Country:US
Mailing Address - Phone:239-624-1050
Mailing Address - Fax:239-624-1051
Practice Address - Street 1:3302 BONITA BEACH RD
Practice Address - Street 2:# 170
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-4174
Practice Address - Country:US
Practice Address - Phone:239-624-1050
Practice Address - Fax:239-624-1051
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2017-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103328363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292464100Medicaid
FLY01QXOtherBCBS
FLU684UOtherMEDICARE
FL292464100Medicaid
FLQ62135Medicare UPIN