Provider Demographics
NPI:1821199332
Name:MCDONALD, TERESA ANN (FNP)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:ANN
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 RIVER DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437
Mailing Address - Country:US
Mailing Address - Phone:707-964-7241
Mailing Address - Fax:707-964-1192
Practice Address - Street 1:721 RIVER DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437
Practice Address - Country:US
Practice Address - Phone:707-964-7241
Practice Address - Fax:707-964-1192
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP11548363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP07504Medicare UPIN