Provider Demographics
NPI:1760782650
Name:WHITLATCH, TERESA (APN FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:TERESA
Middle Name:
Last Name:WHITLATCH
Suffix:
Gender:F
Credentials:APN FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 E UNIVERSITY AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3873
Mailing Address - Country:US
Mailing Address - Phone:217-352-9755
Mailing Address - Fax:
Practice Address - Street 1:410 E UNIVERSITY AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3873
Practice Address - Country:US
Practice Address - Phone:217-352-9755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-26
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.008408363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily