=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194272229
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TERESE TRUAX
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2016
-----------------------------------------------------
Last Update Date | 09/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 244 PEACHTREE ST STE A
-----------------------------------------------------
City | JESUP
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31545-0212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-545-9398
-----------------------------------------------------
Fax | 125-592-0839
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1520
-----------------------------------------------------
City | HINESVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31310-8520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-545-9398
-----------------------------------------------------
Fax | 912-545-2047
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | RN173035
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------