Individual
JESSICA PROVO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
90 ROUTE 6A UNIT 5A, SANDWICH, MA 02563-5301
(508) 477-7090
Mailing address
PO BOX 19305, CHARLOTTE, NC 28219-9305
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
2019-00724
NC
Other
Enumeration date
05/11/2016
Last updated
04/22/2025
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