Provider Demographics
NPI:1689830168
Name:DILLARD, TERESA T (PNP)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:T
Last Name:DILLARD
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 505487
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5487
Mailing Address - Country:US
Mailing Address - Phone:314-525-0580
Mailing Address - Fax:314-525-0581
Practice Address - Street 1:3844 S LINDBERGH BLVD
Practice Address - Street 2:STE 216
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1416
Practice Address - Country:US
Practice Address - Phone:314-525-0580
Practice Address - Fax:314-525-0581
Is Sole Proprietor?:No
Enumeration Date:2008-08-04
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO124737363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO429048309Medicaid