Provider Demographics
NPI:1942751813
Name:COLLETTI, TERESA M (ARNP)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:M
Last Name:COLLETTI
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 1:2125 CRYSTAL GROVE DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-6875
Mailing Address - Country:US
Mailing Address - Phone:863-688-2334
Mailing Address - Fax:
Practice Address - Street 1:2125 CRYSTAL GROVE DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-6875
Practice Address - Country:US
Practice Address - Phone:863-688-2334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-17
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1684252363L00000X
FL1684252310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility