Provider Demographics
NPI:1356943054
Name:ETHERTON, TERESA JO (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:JO
Last Name:ETHERTON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8229 SHOAL CREEK BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-7556
Mailing Address - Country:US
Mailing Address - Phone:817-939-1322
Mailing Address - Fax:
Practice Address - Street 1:8229 SHOAL CREEK BLVD STE 105
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-7556
Practice Address - Country:US
Practice Address - Phone:737-245-7587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1019215363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner