Provider Demographics
NPI:1922176437
Name:HALLIBURTON, THERESA B (CRNA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:B
Last Name:HALLIBURTON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:B
Other - Last Name:MCDERMOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRA
Mailing Address - Street 1:PO BOX 11880
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72917-1880
Mailing Address - Country:US
Mailing Address - Phone:479-452-1581
Mailing Address - Fax:479-452-2149
Practice Address - Street 1:11115 SO WALDRON RD
Practice Address - Street 2:107
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-2584
Practice Address - Country:US
Practice Address - Phone:479-452-1581
Practice Address - Fax:479-452-2148
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC01018 CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR136416701Medicaid
AR5U294Medicare UPIN