Healthcare Provider Details

I. General information

NPI: 1679088173
Provider Name (Legal Business Name): DONNA TEEGARDEN RN CDE MLDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2017
Last Update Date: 12/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

429 FRANKFORT ST
BROOKSVILLE KY
41004-8312
US

IV. Provider business mailing address

PO BOX 117
BROOKSVILLE KY
41004-0117
US

V. Phone/Fax

Practice location:
  • Phone: 606-735-2157
  • Fax: 606-735-2159
Mailing address:
  • Phone: 606-735-2157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number1083603
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: