Basic Information
| Provider Information | |||||||||
| NPI: | 1104182237 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YZENSKI | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | FAY | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 804 E 16TH AVE | ||||||||
| Address2: | |||||||||
| City: | CORDELE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310151514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292738881 | ||||||||
| FaxNumber: | 2292738985 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 PERRY HWY STE 206 | ||||||||
| Address2: | PROFESSIONAL BUILDING B | ||||||||
| City: | HAWKINSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310366748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787839340 | ||||||||
| FaxNumber: | 4787833961 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2012 | ||||||||
| LastUpdateDate: | 03/08/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | RN102774 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 003122631E | 05 | GA | MEDICAID |