1124395892 NPI number — MRS. THERESA TICKLE OWENS NP

Table of content: MRS. THERESA TICKLE OWENS NP (NPI 1124395892)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124395892 NPI number — MRS. THERESA TICKLE OWENS NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OWENS
Provider First Name:
THERESA
Provider Middle Name:
TICKLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NORMAN
Provider Other First Name:
THERESA
Provider Other Middle Name:
TICKLE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1124395892
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
710 W RIDGE RD STE 220
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WYTHEVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24382-1095
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-223-3200
Provider Business Mailing Address Fax Number:
276-223-0617

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
710 W RIDGE RD STE 220
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WYTHEVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24382-1095
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-223-3200
Provider Business Practice Location Address Fax Number:
276-223-0617
Provider Enumeration Date:
11/25/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  0001187004 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 0017140293 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 0024169460 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)