Provider Demographics
NPI:1699195438
Name:TEDDER, JOIE (APRN)
Entity Type:Individual
Prefix:MS
First Name:JOIE
Middle Name:
Last Name:TEDDER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3269 N STOCKTON HILL RD
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3619
Mailing Address - Country:US
Mailing Address - Phone:928-757-2102
Mailing Address - Fax:
Practice Address - Street 1:3801 SANTA ROSA DR STE 400
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-2311
Practice Address - Country:US
Practice Address - Phone:928-681-8750
Practice Address - Fax:928-681-8749
Is Sole Proprietor?:No
Enumeration Date:2014-04-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS76315363L00000X, 363LF0000X
AZ235928363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201108380AMedicaid
KS201108380AMedicaid