Provider Demographics
NPI:1679112254
Name:HUMPHREY, THERESA ANN
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 HAMMILL LN
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-1004
Mailing Address - Country:US
Mailing Address - Phone:775-824-2323
Mailing Address - Fax:775-824-2324
Practice Address - Street 1:517 HAMMILL LN
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-1004
Practice Address - Country:US
Practice Address - Phone:775-824-2323
Practice Address - Fax:775-824-2324
Is Sole Proprietor?:No
Enumeration Date:2019-12-31
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant