Provider Demographics
NPI:1467416917
Name:WAITE, TERESA ROSE (CPNP)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:ROSE
Last Name:WAITE
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 E WAYNE ST STE 124
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:OH
Mailing Address - Zip Code:45822-3304
Mailing Address - Country:US
Mailing Address - Phone:419-586-7940
Mailing Address - Fax:
Practice Address - Street 1:909 E WAYNE ST STE 124
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:OH
Practice Address - Zip Code:45822-3304
Practice Address - Country:US
Practice Address - Phone:419-586-7940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-04831363LP0200X
VA024170075363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics