Provider Demographics
NPI:1356398465
Name:TEDESCO, JANEL NICOLE (ACNP)
Entity type:Individual
Prefix:
First Name:JANEL
Middle Name:NICOLE
Last Name:TEDESCO
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 N WALDROP DR STE 509
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76012-4703
Mailing Address - Country:US
Mailing Address - Phone:817-394-4300
Mailing Address - Fax:
Practice Address - Street 1:15790 PAUL VEGA DR
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1436
Practice Address - Country:US
Practice Address - Phone:985-230-3066
Practice Address - Fax:985-230-2072
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX687805363LA2100X
LAAP09592363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX183678501Medicaid
TX8J0253Medicare PIN