Basic Information
| Provider Information | |||||||||
| NPI: | 1316371776 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GODFREY | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | CHRISTINE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN, BS, MS, FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KOSS | ||||||||
| OtherFirstName: | TERESA | ||||||||
| OtherMiddleName: | CHRISTINE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 405 LAKE ZURICH RD | ||||||||
| Address2: | |||||||||
| City: | BARRINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600103141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473815599 | ||||||||
| FaxNumber: | 8473818042 | ||||||||
| Practice Location | |||||||||
| Address1: | 405 LAKE ZURICH RD | ||||||||
| Address2: | |||||||||
| City: | BARRINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600103141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473815599 | ||||||||
| FaxNumber: | 8473818042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2013 | ||||||||
| LastUpdateDate: | 11/23/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209-010114 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.