Provider Demographics
NPI:1356344097
Name:AVERION, THERESA PAMPLONA (APRN)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:PAMPLONA
Last Name:AVERION
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:I
Other - Last Name:PAMPLONA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4 HIBBING WAY
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-7044
Mailing Address - Country:US
Mailing Address - Phone:203-561-9467
Mailing Address - Fax:
Practice Address - Street 1:4 HIBBING WAY
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-7044
Practice Address - Country:US
Practice Address - Phone:203-561-9467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-26
Last Update Date:2009-05-12
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-04-11
Provider Licenses
StateLicense IDTaxonomies
CT003090363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTQ037349Medicare UPIN
CT500001416Medicare ID - Type Unspecified