MEDICARE: MRS. TERESA A THACKER ARNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner	ARNP9449096	FL
2	363LF0000X	Family Nurse Practitioner	ARNP9449096	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1326152570	OTHER	KY	NPI

General Provider Information

NPI Number	:	1326152570
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TERESA A THACKER ARNP

Provider Business Mailing Address
First Line	:	PO BOX 2147
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33902-2147
Country	:	US
Telephone Number	:	239-343-9888
Fax Number	:	239-303-0714

Provider Business Practice Location Address
First Line	:	260 BETH STACEY BLVD STE C
Second Line	:
City	:	LEHIGH ACRES
State	:	FL
Zip	:	33936-6074
Country	:	US
Telephone Number	:	239-343-9888
Fax Number	:	239-303-0714

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/17/2006
Last Update Date	:	03/30/2021

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