MEDICARE: MRS. TERESA JO ETHERTON FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	1019215	TX

General Provider Information

NPI Number	:	1356943054
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TERESA JO ETHERTON FNP-C

Provider Business Mailing Address
First Line	:	8229 SHOAL CREEK BLVD STE 105
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78757-7556
Country	:	US
Telephone Number	:	817-939-1322
Fax Number	:

Provider Business Practice Location Address
First Line	:	8229 SHOAL CREEK BLVD STE 105
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78757-7556
Country	:	US
Telephone Number	:	737-245-7587
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2020
Last Update Date	:	02/15/2023

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