Provider Demographics
NPI:1356500300
Name:DUMAINE, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:DUMAINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:
Other - Last Name:MCMURTRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:722 LOUGHBOROUGH AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63111-2732
Mailing Address - Country:US
Mailing Address - Phone:314-833-4030
Mailing Address - Fax:314-833-4031
Practice Address - Street 1:9417 S BROADWAY
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63125-2009
Practice Address - Country:US
Practice Address - Phone:314-833-4030
Practice Address - Fax:314-833-4031
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019000531363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily