Healthcare Provider Details

I. General information

NPI: 1629051503
Provider Name (Legal Business Name): TERESA BLAIR APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 10/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 TISDELL AVE
WARREN IL
61087
US

IV. Provider business mailing address

421 W EXCHANGE ST PO BOX 268
FREEPORT IL
61032-4008
US

V. Phone/Fax

Practice location:
  • Phone: 815-745-2644
  • Fax: 815-745-2546
Mailing address:
  • Phone: 815-599-7958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209005291
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: