Provider Demographics
NPI:1992214050
Name:WADE, TERESA NICOLE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:NICOLE
Last Name:WADE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:TERESA
Other - Middle Name:NICOLE
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2880 SAGE AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-4231
Mailing Address - Country:US
Mailing Address - Phone:937-305-7624
Mailing Address - Fax:
Practice Address - Street 1:2880 SAGE AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-4231
Practice Address - Country:US
Practice Address - Phone:937-305-7624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-21
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH112114164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPN112114OtherLPN