Healthcare Provider Details

I. General information

NPI: 1982020392
Provider Name (Legal Business Name): TERESA LYNN ANDERSON RN/CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2014
Last Update Date: 03/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

472 CHALAN SAN ANTONIO PEMAR PLACE C/O: MARIANAS PHYSICIAN GROUP
TAMUNING GU
96913
US

IV. Provider business mailing address

472 CHALAN SAN ANTONIO PEMAR PLACE C/O: MARIANAS PHYSICIAN GROUP
TAMUNING GU
96913
US

V. Phone/Fax

Practice location:
  • Phone: 671-647-1830
  • Fax:
Mailing address:
  • Phone: 671-647-1830
  • Fax: 647-647-1919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberNP-0124
License Number StateGU
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRE-1861
License Number StateGU

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: