Provider Demographics
NPI:1508992496
Name:BRAKE, TERESA MAE (LVN)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:MAE
Last Name:BRAKE
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:MAE
Other - Last Name:WRIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 317
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95927-0317
Mailing Address - Country:US
Mailing Address - Phone:530-345-1668
Mailing Address - Fax:
Practice Address - Street 1:23 AMBER WAY
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-1701
Practice Address - Country:US
Practice Address - Phone:530-345-1668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN175535164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARVN004280Medicare UPIN
CAEPS016120Medicare UPIN