Provider Demographics
NPI:1225150741
Name:MARTISAK, TERESA ANN (RN CDE)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:ANN
Last Name:MARTISAK
Suffix:
Gender:F
Credentials:RN CDE
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 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:541-732-6957
Mailing Address - Fax:541-732-7901
Practice Address - Street 1:1698 E MCANDREWS RD
Practice Address - Street 2:SUITE 170
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-5589
Practice Address - Country:US
Practice Address - Phone:541-732-6957
Practice Address - Fax:541-732-7901
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR086006602163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR086006602RNOtherRN LICENSE