Provider Demographics
NPI:1821196700
Name:LEDESMA, THERESA A (ARNP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:LEDESMA
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3421 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5401
Mailing Address - Country:US
Mailing Address - Phone:319-272-7303
Mailing Address - Fax:319-272-7318
Practice Address - Street 1:201 8TH AVE SE
Practice Address - Street 2:
Practice Address - City:OELWEIN
Practice Address - State:IA
Practice Address - Zip Code:50662-2447
Practice Address - Country:US
Practice Address - Phone:319-283-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA080263207P00000X, 363L00000X, 363LF0000X, 364SE0003X, 363LC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SE0003XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistEmergency
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0074625Medicaid
I12926Medicare ID - Type Unspecified
IA0074625Medicaid
IAP16372Medicare UPIN