Provider Demographics
NPI:1164756649
Name:DETOMASO, THERESA MARIA (LPN)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:MARIA
Last Name:DETOMASO
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:PO BOX 645
Mailing Address - Street 2:
Mailing Address - City:FORT RECOVERY
Mailing Address - State:OH
Mailing Address - Zip Code:45846-0645
Mailing Address - Country:US
Mailing Address - Phone:419-953-7730
Mailing Address - Fax:
Practice Address - Street 1:806 BLUE JACKET DR
Practice Address - Street 2:APT. B
Practice Address - City:FORT RECOVERY
Practice Address - State:OH
Practice Address - Zip Code:45846-0645
Practice Address - Country:US
Practice Address - Phone:419-953-7730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-30
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN130615IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse