Provider Demographics
NPI:1972683753
Name:MORTENSEN, THERESA LOUISE (NP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:LOUISE
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3555 ROUND BARN CIR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-1757
Mailing Address - Country:US
Mailing Address - Phone:707-528-1050
Mailing Address - Fax:707-525-3874
Practice Address - Street 1:3555 ROUND BARN CIR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-1757
Practice Address - Country:US
Practice Address - Phone:707-528-1050
Practice Address - Fax:707-525-3874
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA402482363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN402482Medicaid
CARN402482Medicaid