Basic Information
| Provider Information | |||||||||
| NPI: | 1952499543 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRIFFIN | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246450 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11937 US HIGHWAY 271 | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757083154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038773451 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 02/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 649261 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 752616977077 | 01 | TX | TRICARE | OTHER | 8Y1348 | 01 | TX | BCBS OF TEXAS | OTHER | 191703102 | 05 | TX | MEDICAID | 878N78 | 01 | TX | BCBS | OTHER | 191703101 | 05 | TX | MEDICAID |