Provider Demographics
NPI:1942606496
Name:PUGH, THERESA (RN)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:PUGH
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 1:1053 CROWN LANDING PKWY
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-8717
Mailing Address - Country:US
Mailing Address - Phone:678-249-4796
Mailing Address - Fax:
Practice Address - Street 1:155 WESTRIDGE PKWY STE 225
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-3052
Practice Address - Country:US
Practice Address - Phone:678-251-9922
Practice Address - Fax:678-782-5924
Is Sole Proprietor?:No
Enumeration Date:2014-11-11
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN181879171M00000X, 163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No171M00000XOther Service ProvidersCase Manager/Care Coordinator