Provider Demographics
NPI:1477625531
Name:TEAGUE, CAROL A (FNP)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:A
Last Name:TEAGUE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 W 10TH ST
Mailing Address - Street 2:ATTN: EXECUTIVE DIRECTOR OF PHYSICIAN CLINICS
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-2905
Mailing Address - Country:US
Mailing Address - Phone:573-364-9000
Mailing Address - Fax:
Practice Address - Street 1:1000 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:ST JAMES
Practice Address - State:MO
Practice Address - Zip Code:65401
Practice Address - Country:US
Practice Address - Phone:573-265-8840
Practice Address - Fax:573-265-8884
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO076310363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1477625531Medicaid
MO424848406Medicaid
MOS97414Medicare UPIN
MO000080862Medicare ID - Type Unspecified
MO424848406Medicaid