Provider Demographics
NPI:1942976592
Name:HAMMON, TELIETHA ANN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:TELIETHA
Middle Name:ANN
Last Name:HAMMON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1880 JOHN ADAMS PKWY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4315
Mailing Address - Country:US
Mailing Address - Phone:208-524-6633
Mailing Address - Fax:208-524-9952
Practice Address - Street 1:1880 JOHN ADAMS PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4315
Practice Address - Country:US
Practice Address - Phone:208-524-6633
Practice Address - Fax:208-524-9952
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID69144363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily