Provider Demographics
NPI:1124395892
Name:OWENS, THERESA TICKLE (NP)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:TICKLE
Last Name:OWENS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:THERESA
Other - Middle Name:TICKLE
Other - Last Name:NORMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:710 W RIDGE RD STE 220
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-1095
Mailing Address - Country:US
Mailing Address - Phone:276-223-3200
Mailing Address - Fax:276-223-0617
Practice Address - Street 1:710 W RIDGE RD STE 220
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-1095
Practice Address - Country:US
Practice Address - Phone:276-223-3200
Practice Address - Fax:276-223-0617
Is Sole Proprietor?:No
Enumeration Date:2011-11-25
Last Update Date:2019-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001187004163W00000X
VA0017140293363L00000X
VA0024169460363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner