Provider Demographics
NPI:1407473465
Name:TEASLEY, SAGE (EMT)
Entity Type:Individual
Prefix:
First Name:SAGE
Middle Name:
Last Name:TEASLEY
Suffix:
Gender:F
Credentials:EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11212 HUNTING HORSE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX STATION
Mailing Address - State:VA
Mailing Address - Zip Code:22039-2017
Mailing Address - Country:US
Mailing Address - Phone:703-347-5682
Mailing Address - Fax:
Practice Address - Street 1:11212 HUNTING HORSE DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX STATION
Practice Address - State:VA
Practice Address - Zip Code:22039-2017
Practice Address - Country:US
Practice Address - Phone:703-347-5682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-25
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA19-1016146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic