Provider Demographics
NPI:1962005785
Name:GREGG, THERESA (RNFA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:GREGG
Suffix:
Gender:F
Credentials:RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-5504
Mailing Address - Country:US
Mailing Address - Phone:315-359-2670
Mailing Address - Fax:315-359-2675
Practice Address - Street 1:1200 DRIVING PARK AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-1090
Practice Address - Country:US
Practice Address - Phone:315-359-2670
Practice Address - Fax:315-359-2675
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY433982163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant