Provider Demographics
NPI:1477033868
Name:HADDOX, THERESA LYNN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:LYNN
Last Name:HADDOX
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 LONDONDERRY DR STE 200
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-7930
Mailing Address - Country:US
Mailing Address - Phone:254-751-9777
Mailing Address - Fax:
Practice Address - Street 1:333 LONDONDERRY DR STE 200
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-7930
Practice Address - Country:US
Practice Address - Phone:254-751-9777
Practice Address - Fax:254-751-9788
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-15
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X
TXAP142913207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
No251E00000XAgenciesHome HealthGroup - Single Specialty