Provider Demographics
NPI:1033684659
Name:SMALL, THERESA (CNM, APRN)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:SMALL
Suffix:
Gender:F
Credentials:CNM, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7291
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04243-7291
Mailing Address - Country:US
Mailing Address - Phone:207-777-8202
Mailing Address - Fax:
Practice Address - Street 1:168 KINSLEY ST STE 19
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-3634
Practice Address - Country:US
Practice Address - Phone:603-595-3951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH041620-23163WR0006X, 363LX0001X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology