Provider Demographics
NPI:1851545727
Name:LANDRY, THERESE A (ARNP)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:A
Last Name:LANDRY
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 1:3130 ELLIS ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-1904
Mailing Address - Country:US
Mailing Address - Phone:360-734-4404
Mailing Address - Fax:
Practice Address - Street 1:3130 ELLIS ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1904
Practice Address - Country:US
Practice Address - Phone:360-734-4404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00168143163W00000X
WAAP30007538163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9639998Medicaid
P91503Medicare UPIN
R116181Medicare PIN