Healthcare Provider Details

I. General information

NPI: 1255682563
Provider Name (Legal Business Name): TERESA LYNN BUSH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2012
Last Update Date: 09/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 E STATE ST
GLOVERSVILLE NY
12078-1204
US

IV. Provider business mailing address

PO BOX 588
CAROGA LAKE NY
12032-0588
US

V. Phone/Fax

Practice location:
  • Phone: 518-773-7931
  • Fax:
Mailing address:
  • Phone: 518-835-2616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number657598
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: