Healthcare Provider Details

I. General information

NPI: 1629518410
Provider Name (Legal Business Name): MARY JANE TEETERS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2017
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 SPRING VALLEY DR
HUNTINGTON WV
25704-9501
US

IV. Provider business mailing address

PO BOX 406
PRESTONSBURG KY
41653-0406
US

V. Phone/Fax

Practice location:
  • Phone: 304-710-7790
  • Fax: 215-842-4233
Mailing address:
  • Phone: 606-886-7602
  • Fax: 606-886-1316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3010972
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: