Provider Demographics
NPI:1003923699
Name:WAUGH, TERESA GAYLE (RN, CDE)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:GAYLE
Last Name:WAUGH
Suffix:
Gender:F
Credentials:RN, CDE
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:GAYLE
Other - Last Name:KEENEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:RT 1 BOX 173 K
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:WV
Mailing Address - Zip Code:25124
Mailing Address - Country:US
Mailing Address - Phone:304-586-3012
Mailing Address - Fax:
Practice Address - Street 1:3110 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304
Practice Address - Country:US
Practice Address - Phone:304-388-5555
Practice Address - Fax:304-355-5560
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV45590163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator