Provider Demographics
NPI:1255682563
Name:BUSH, TERESA LYNN (RN)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:LYNN
Last Name:BUSH
Suffix:
Gender:F
Credentials:RN
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 588
Mailing Address - Street 2:
Mailing Address - City:CAROGA LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12032-0588
Mailing Address - Country:US
Mailing Address - Phone:518-835-2616
Mailing Address - Fax:
Practice Address - Street 1:127 E STATE ST
Practice Address - Street 2:
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078-1204
Practice Address - Country:US
Practice Address - Phone:518-773-7931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY657598163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse