Provider Demographics
NPI:1134464084
Name:O'LEARY, THERESA DEANN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:DEANN
Last Name:O'LEARY
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 1:6216 119TH AVE E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-2825
Mailing Address - Country:US
Mailing Address - Phone:253-268-0808
Mailing Address - Fax:
Practice Address - Street 1:1601 26TH AVE SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-1349
Practice Address - Country:US
Practice Address - Phone:253-841-8746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-04
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP00059871164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse