Provider Demographics
NPI:1942368543
Name:DURHAM, TERESSA LINDA
Entity Type:Individual
Prefix:MRS
First Name:TERESSA
Middle Name:LINDA
Last Name:DURHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11186 N HAUSER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:HAUSER
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5638
Mailing Address - Country:US
Mailing Address - Phone:208-457-1515
Mailing Address - Fax:
Practice Address - Street 1:11186 N HAUSER LAKE RD
Practice Address - Street 2:
Practice Address - City:HAUSER
Practice Address - State:ID
Practice Address - Zip Code:83854-5638
Practice Address - Country:US
Practice Address - Phone:208-457-1515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty