Provider Demographics
NPI:1609053792
Name:HUMPHREY, TERESA M (RN)
Entity Type:Individual
Prefix:MS
First Name:TERESA
Middle Name:M
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4611 N MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:53211-1121
Mailing Address - Country:US
Mailing Address - Phone:414-243-9851
Mailing Address - Fax:262-548-8084
Practice Address - Street 1:4611 N MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:WI
Practice Address - Zip Code:53211-1121
Practice Address - Country:US
Practice Address - Phone:414-243-9851
Practice Address - Fax:262-548-8084
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI91497-030163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39863800Medicaid