Provider Demographics
NPI:1821392424
Name:GANNON, TERESA A (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:A
Last Name:GANNON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39621 N WHITE TAIL LN
Mailing Address - Street 2:
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-3683
Mailing Address - Country:US
Mailing Address - Phone:518-878-7491
Mailing Address - Fax:
Practice Address - Street 1:39621 N WHITE TAIL LN
Practice Address - Street 2:
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086-3683
Practice Address - Country:US
Practice Address - Phone:518-878-7491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ285061363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily