1194776039 NPI number — MS. TERESA LYNN TATE APRN,BC

Table of content: MS. TERESA LYNN TATE APRN,BC (NPI 1194776039)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194776039 NPI number — MS. TERESA LYNN TATE APRN,BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TATE
Provider First Name:
TERESA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
APRN,BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HANFT
Provider Other First Name:
TERESA
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN-BC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1194776039
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
106 LOCKHEED DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEAVER
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25813-8962
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-253-5155
Provider Business Mailing Address Fax Number:
304-536-5031

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106 LOCKHEED DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEAVER
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25813-8962
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-253-5155
Provider Business Practice Location Address Fax Number:
691-207-7011
Provider Enumeration Date:
05/15/2006

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: 363LF0000X , with the licence number:  51350 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1611 . This is a "RXA" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 3810007225 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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