Provider Demographics
NPI:1679024798
Name:DISTLER, TERESA ANNE (NP-C)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:ANNE
Last Name:DISTLER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12103 COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65074-2814
Mailing Address - Country:US
Mailing Address - Phone:573-690-6271
Mailing Address - Fax:
Practice Address - Street 1:4430 MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473-9098
Practice Address - Country:US
Practice Address - Phone:573-596-1765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-24
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016037029363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily