Basic Information
| Provider Information | |||||||||
| NPI: | 1053379727 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | PTA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | ANKRUM | ||||||||
| OtherFirstName: | TERESA | ||||||||
| OtherMiddleName: | LYNN | ||||||||
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| OtherCredential: | PTA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 461 | ||||||||
| Address2: | |||||||||
| City: | NEVADA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502010461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5153823366 | ||||||||
| FaxNumber: | 5153821576 | ||||||||
| Practice Location | |||||||||
| Address1: | 610 10TH ST | ||||||||
| Address2: | |||||||||
| City: | PERRY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 50220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5154657672 | ||||||||
| FaxNumber: | 5154657655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 00319 | IA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.