Provider Demographics
NPI:1528433752
Name:FILLINGHAM, JACQUELYN NICOLE (CRNA)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:NICOLE
Last Name:FILLINGHAM
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:NICOLE
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:ONE MEDICAL CENTER DRIVE
Mailing Address - Street 2:ANESTHESIOLOGY
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:ONE MEDICAL CENTER DRIVE
Practice Address - Street 2:ANESTHESIOLOGY
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756-0001
Practice Address - Country:US
Practice Address - Phone:603-650-5922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-14
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANA95000460367500000X
NH087137-23367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered