Provider Demographics
NPI:1245246099
Name:STANFORD, TERESA (NP)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:STANFORD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 MAIN ST N
Mailing Address - Street 2:
Mailing Address - City:AMORY
Mailing Address - State:MS
Mailing Address - Zip Code:38821-3416
Mailing Address - Country:US
Mailing Address - Phone:662-256-7112
Mailing Address - Fax:
Practice Address - Street 1:1105 EARL FRYE BLVD
Practice Address - Street 2:
Practice Address - City:AMORY
Practice Address - State:MS
Practice Address - Zip Code:38821-5500
Practice Address - Country:US
Practice Address - Phone:662-256-9327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR613878363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS121431Medicaid
MS500002083Medicare ID - Type Unspecified