Provider Demographics
NPI:1043549918
Name:STATEN, TEQUILA J (APRN)
Entity Type:Individual
Prefix:MS
First Name:TEQUILA
Middle Name:J
Last Name:STATEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1759
Mailing Address - Country:US
Mailing Address - Phone:270-781-5111
Mailing Address - Fax:
Practice Address - Street 1:5796 NASHVILLE RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101
Practice Address - Country:US
Practice Address - Phone:270-781-6477
Practice Address - Fax:270-781-6479
Is Sole Proprietor?:No
Enumeration Date:2009-12-23
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006238363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100170760Medicaid
KY6238POtherKY BOARD OF NURSING
KYK138260Medicare PIN