=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841076395
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TERESA ANNE BRANNON RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2023
-----------------------------------------------------
Last Update Date | 08/31/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1466 COUNTY ROUTE 29
-----------------------------------------------------
City | OLMSTEDVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-251-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 404 IRISHTOWN RD
-----------------------------------------------------
City | OLMSTEDVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12857-2110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-524-6685
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WS0200X
-----------------------------------------------------
Taxonomy Name | School Registered Nurse
-----------------------------------------------------
License Number | 633485
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------