1689830168 NPI number — MRS. TERESA T DILLARD PNP

Table of content: MRS. TERESA T DILLARD PNP (NPI 1689830168)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689830168 NPI number — MRS. TERESA T DILLARD PNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DILLARD
Provider First Name:
TERESA
Provider Middle Name:
T
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689830168
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/17/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7412049
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60674-2049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-525-0580
Provider Business Mailing Address Fax Number:
314-525-0581

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3844 S LINDBERGH BLVD
Provider Second Line Business Practice Location Address:
STE 216
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63127-1416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-525-0580
Provider Business Practice Location Address Fax Number:
314-525-0581
Provider Enumeration Date:
08/04/2008

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: 363L00000X , with the licence number:  124737 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 429048309 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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