Provider Demographics
NPI:1629672332
Name:FAUNTLEROY, THERESA DENISE
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:DENISE
Last Name:FAUNTLEROY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:DENISE
Other - Last Name:FAUNTLEROY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2111 BELLEVUE AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23509-1861
Mailing Address - Country:US
Mailing Address - Phone:757-439-4418
Mailing Address - Fax:
Practice Address - Street 1:2111 BELLEVUE AVE APT 2
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23509-1861
Practice Address - Country:US
Practice Address - Phone:757-439-4418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant