Provider Demographics
NPI:1588804686
Name:MACDOUGALL, THERESA NAOMI (CERTIFIED NURSE PRAC)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:NAOMI
Last Name:MACDOUGALL
Suffix:
Gender:F
Credentials:CERTIFIED NURSE PRAC
Other - Prefix:MS
Other - First Name:THERESA
Other - Middle Name:NAOMI
Other - Last Name:SUTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CERTIFIED NURSE PRAC
Mailing Address - Street 1:531 FAUNCE CORNER RD
Mailing Address - Street 2:
Mailing Address - City:DARTMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02747-1242
Mailing Address - Country:US
Mailing Address - Phone:508-996-3991
Mailing Address - Fax:
Practice Address - Street 1:531 FAUNCE CORNER RD
Practice Address - Street 2:
Practice Address - City:DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-1242
Practice Address - Country:US
Practice Address - Phone:508-996-3991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-02
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN284223363LF0000X
RIAPRN03228363L00000X
PASP010165363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD951695OtherCAREFIRST MD BCBS
MA110171739AMedicaid
PA1583237OtherGATEWAY-WMG
PA2099584OtherHIGHMARK BLUE SHIELD