Healthcare Provider Details

I. General information

NPI: 1871278747
Provider Name (Legal Business Name): TERESA ANN WENNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2023
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 S DUKE ST STE 104
SHEPHERDSTOWN WV
25443-4849
US

IV. Provider business mailing address

158 HEATH CT
CHARLES TOWN WV
25414-4137
US

V. Phone/Fax

Practice location:
  • Phone: 304-362-3009
  • Fax:
Mailing address:
  • Phone: 130-427-9639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM1400X
TaxonomyNurse Massage Therapist (NMT)
License Number53092
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code163WM1400X
TaxonomyNurse Massage Therapist (NMT)
License Number0001149304
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number53092
License Number StateWV
# 4
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number223-4023
License Number StateWV
# 5
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0019019311
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: