Provider Demographics
NPI:1013243138
Name:GORE, TERESA ANN (ANP-BC)
Entity type:Individual
Prefix:MISS
First Name:TERESA
Middle Name:ANN
Last Name:GORE
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 NEVINS ST
Mailing Address - Street 2:4RD FLOOR
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135
Mailing Address - Country:US
Mailing Address - Phone:617-999-2965
Mailing Address - Fax:
Practice Address - Street 1:11 NEVINS ST
Practice Address - Street 2:SUITE 401
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135
Practice Address - Country:US
Practice Address - Phone:617-782-7788
Practice Address - Fax:617-783-5657
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-23
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN280238363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health