=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467932533
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TERESA MOONEY NP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2018
-----------------------------------------------------
Last Update Date | 12/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 324 LESLIE CT
-----------------------------------------------------
City | BRISTOL
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-646-2864
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 310 MARYLAND AVE
-----------------------------------------------------
City | BECKLEY
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25801-4226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-228-9158
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | APRN82500-NP-C
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------