Healthcare Provider Details

I. General information

NPI: 1568338101
Provider Name (Legal Business Name): TEAGUE LAWRENCE FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2025
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1726 E BEVERLY AVE
KINGMAN AZ
86409-3500
US

IV. Provider business mailing address

1726 E BEVERLY AVE
KINGMAN AZ
86409-3500
US

V. Phone/Fax

Practice location:
  • Phone: 928-753-3303
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number13010100-3102
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number340601
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: