Provider Demographics
NPI:1245699453
Name:SIEFKE, TERESA (MS, AGACNP-BC)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:SIEFKE
Suffix:
Gender:
Credentials:MS, AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3170 KETTERING BLVD BLDG B3
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3188
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:9000 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45415-1180
Practice Address - Country:US
Practice Address - Phone:937-208-8394
Practice Address - Fax:937-208-8388
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-16
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71013185A363LA2100X
FLAPRN11019111363LA2100X
OHCOA.17512-NP363LA2100X
PASP026035363LG0600X
SC27193363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care