Provider Demographics
NPI:1720034556
Name:KOUADIO, THERESA (CMN)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:KOUADIO
Suffix:
Gender:F
Credentials:CMN
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:COLEY-KOUADIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:1717 W COWLES ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-5926
Mailing Address - Country:US
Mailing Address - Phone:907-451-6682
Mailing Address - Fax:
Practice Address - Street 1:1717 W COWLES ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5926
Practice Address - Country:US
Practice Address - Phone:907-451-6682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK139327363L00000X
MA2258071367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner