Healthcare Provider Details

I. General information

NPI: 1437335866
Provider Name (Legal Business Name): THERESA LERCH C FNP CNM PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2008
Last Update Date: 12/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 E BROADWAY SUITE 1C
JACKSON WY
83001
US

IV. Provider business mailing address

PO BOX 9487
JACKSON WY
83002-9487
US

V. Phone/Fax

Practice location:
  • Phone: 307-733-4585
  • Fax: 307-733-4787
Mailing address:
  • Phone: 307-733-4585
  • Fax: 307-733-4787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number18054.0164
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number18054.0164
License Number StateWY

VIII. Authorized Official

Name: THERESA LERCH
Title or Position: PRESIDENT
Credential: C-FNP, CNM
Phone: 307-733-4585