Healthcare Provider Details

I. General information

NPI: 1003923699
Provider Name (Legal Business Name): TERESA GAYLE WAUGH RN, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TERESA GAYLE KEENEY

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 06/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3110 MACCORKLE AVE SE
CHARLESTON WV
25304
US

IV. Provider business mailing address

RT 1 BOX 173 K
LIBERTY WV
25124
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-5555
  • Fax: 304-355-5560
Mailing address:
  • Phone: 304-586-3012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number45590
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: