Provider Demographics
NPI:1588665202
Name:LUND, TERESE J (APN)
Entity Type:Individual
Prefix:
First Name:TERESE
Middle Name:J
Last Name:LUND
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 S 21ST ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-4323
Mailing Address - Country:US
Mailing Address - Phone:307-745-5364
Mailing Address - Fax:
Practice Address - Street 1:413 S 21ST ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-4323
Practice Address - Country:US
Practice Address - Phone:307-745-5364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY10010.189363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1130731-00Medicaid
WY1130731-00Medicaid