Healthcare Provider Details

I. General information

NPI: 1013011337
Provider Name (Legal Business Name): TERESA TYSON FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TERESA GARDNER FNP-BC

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 03/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 FRONT ST W
COEBURN VA
24230-3502
US

IV. Provider business mailing address

PO BOX 90
COEBURN VA
24230-0090
US

V. Phone/Fax

Practice location:
  • Phone: 276-455-5556
  • Fax:
Mailing address:
  • Phone: 276-328-8850
  • Fax: 276-328-8853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024119161
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: