Provider Demographics
NPI:1821583220
Name:BASHAW, TERESA GAIL (RN)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:GAIL
Last Name:BASHAW
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 HIGHWAY 222
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-7090
Mailing Address - Country:US
Mailing Address - Phone:501-463-3799
Mailing Address - Fax:
Practice Address - Street 1:415 HIGHWAY 222
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-7090
Practice Address - Country:US
Practice Address - Phone:501-463-3799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR0039905163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse