Basic Information
| Provider Information | |||||||||
| NPI: | 1326411679 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5012 US HWY 75 S, SUITE 300 | ||||||||
| Address2: | ATTN BILLING | ||||||||
| City: | DENISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8063517200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 301 N 23RD ST STE C | ||||||||
| Address2: | |||||||||
| City: | CANYON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 790153058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8064525522 | ||||||||
| FaxNumber: | 8064523070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2015 | ||||||||
| LastUpdateDate: | 08/16/2019 | ||||||||
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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 | 363LF0000X | AP128156 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | AP128156 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 3626103-01 | 05 | TX | MEDICAID |