Provider Demographics
NPI:1093794679
Name:TEAGUE, MARLYN C (NP)
Entity Type:Individual
Prefix:
First Name:MARLYN
Middle Name:C
Last Name:TEAGUE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12108 RANLEIGH CT
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-5525
Mailing Address - Country:US
Mailing Address - Phone:919-846-6625
Mailing Address - Fax:
Practice Address - Street 1:12108 RANLEIGH CT
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27613-5525
Practice Address - Country:US
Practice Address - Phone:919-846-6625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCF0303059363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC201809Medicare UPIN