Healthcare Provider Details

I. General information

NPI: 1568654903
Provider Name (Legal Business Name): MALINDA TEAGUE CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2007
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2406 BLUE RIDGE RD STE 100
RALEIGH NC
27607
US

IV. Provider business mailing address

5213 S ALSTON AVE
DURHAM NC
27713-4430
US

V. Phone/Fax

Practice location:
  • Phone: 919-786-5001
  • Fax: 919-786-5051
Mailing address:
  • Phone: 919-620-4855
  • Fax: 919-620-4921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number250343
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number209-004496
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5010373
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number286171
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: