Provider Demographics
NPI:1013415280
Name:LEVAN, TERESA RAE
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:RAE
Last Name:LEVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:OH
Mailing Address - Zip Code:43783-9586
Mailing Address - Country:US
Mailing Address - Phone:740-836-5018
Mailing Address - Fax:
Practice Address - Street 1:208 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:OH
Practice Address - Zip Code:43783-9586
Practice Address - Country:US
Practice Address - Phone:740-836-5018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0191212374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0191212Medicaid