Provider Demographics
NPI:1760857445
Name:WELLISLEY, JENNIFER (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WELLISLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8718 HAW RIVER RD
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-9061
Mailing Address - Country:US
Mailing Address - Phone:570-809-3786
Mailing Address - Fax:
Practice Address - Street 1:1301 CASTLEPOINTE DR
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-4351
Practice Address - Country:US
Practice Address - Phone:919-401-1994
Practice Address - Fax:919-401-1924
Is Sole Proprietor?:No
Enumeration Date:2015-12-07
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5013076363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily