Provider Demographics
NPI:1326783754
Name:CRUDUP, TERESA D (CNA)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:D
Last Name:CRUDUP
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 ROAMING FAWN DR
Mailing Address - Street 2:
Mailing Address - City:ROCKWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37854-4871
Mailing Address - Country:US
Mailing Address - Phone:865-318-6865
Mailing Address - Fax:865-285-9612
Practice Address - Street 1:103 ROAMING FAWN DR
Practice Address - Street 2:
Practice Address - City:ROCKWOOD
Practice Address - State:TN
Practice Address - Zip Code:37854-4871
Practice Address - Country:US
Practice Address - Phone:865-318-6865
Practice Address - Fax:865-285-9612
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-29
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00149507376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN629114300OtherDEPARTMENT OF LABOR PROVIDER NUMBER DEEOIC