Provider Demographics
NPI:1578939112
Name:WANAMAKER, TERESA
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:
Last Name:WANAMAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 WILLOW TREE RD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:NY
Mailing Address - Zip Code:12547-5306
Mailing Address - Country:US
Mailing Address - Phone:845-795-1226
Mailing Address - Fax:
Practice Address - Street 1:120 WILLOW TREE RD
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:NY
Practice Address - Zip Code:12547-5306
Practice Address - Country:US
Practice Address - Phone:845-795-1226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-18
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist