Provider Demographics
NPI:1104039528
Name:WITHAM, TERESA A (LPN)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:A
Last Name:WITHAM
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 S MCDONALD ST
Mailing Address - Street 2:
Mailing Address - City:THE PLAINS
Mailing Address - State:OH
Mailing Address - Zip Code:45780-1250
Mailing Address - Country:US
Mailing Address - Phone:740-707-1141
Mailing Address - Fax:
Practice Address - Street 1:27 S MCDONALD ST
Practice Address - Street 2:
Practice Address - City:THE PLAINS
Practice Address - State:OH
Practice Address - Zip Code:45780-1250
Practice Address - Country:US
Practice Address - Phone:740-707-1141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN098990164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2248839OtherSTATE ID NUMBER