Provider Demographics
NPI:1932304516
Name:TEAQUE, NETTIE LOUISE (FOSTER CARE PARENT)
Entity Type:Individual
Prefix:MRS
First Name:NETTIE
Middle Name:LOUISE
Last Name:TEAQUE
Suffix:
Gender:F
Credentials:FOSTER CARE PARENT
Other - Prefix:MRS
Other - First Name:NETTIE
Other - Middle Name:LOUISE
Other - Last Name:TEAQUE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FOSTER CARE PARENT
Mailing Address - Street 1:RT 1 BOX 856
Mailing Address - Street 2:
Mailing Address - City:SPERRY
Mailing Address - State:OK
Mailing Address - Zip Code:74073
Mailing Address - Country:US
Mailing Address - Phone:918-288-6231
Mailing Address - Fax:918-288-6231
Practice Address - Street 1:RT 1 BOX 856
Practice Address - Street 2:
Practice Address - City:SPERRY
Practice Address - State:OK
Practice Address - Zip Code:74073
Practice Address - Country:US
Practice Address - Phone:918-288-6231
Practice Address - Fax:918-288-6231
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK177F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes177F00000XOther Service ProvidersLodging