Provider Demographics
NPI:1013011337
Name:TYSON, TERESA (FNP-BC)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:TYSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:PO BOX 90
Mailing Address - Street 2:
Mailing Address - City:COEBURN
Mailing Address - State:VA
Mailing Address - Zip Code:24230-0090
Mailing Address - Country:US
Mailing Address - Phone:276-328-8850
Mailing Address - Fax:276-328-8853
Practice Address - Street 1:208 FRONT ST W
Practice Address - Street 2:
Practice Address - City:COEBURN
Practice Address - State:VA
Practice Address - Zip Code:24230-3502
Practice Address - Country:US
Practice Address - Phone:276-455-5556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024119161363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA01059873Medicaid
VA01059873Medicaid
VAQ28454Medicare UPIN