Provider Demographics
NPI:1194863431
Name:KORMOS, THERESA C (MSN, RN)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:C
Last Name:KORMOS
Suffix:
Gender:F
Credentials:MSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 CEDAR PLAZA PKWY
Mailing Address - Street 2:SUITE 350
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-3854
Mailing Address - Country:US
Mailing Address - Phone:314-843-4333
Mailing Address - Fax:314-843-4856
Practice Address - Street 1:1201 BELLEVUE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1701
Practice Address - Country:US
Practice Address - Phone:314-647-4488
Practice Address - Fax:314-647-6305
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO146030364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO423961911Medicaid
MO002013303Medicare ID - Type Unspecified
MO423961911Medicaid