Provider Demographics
NPI:1396086542
Name:AUSTIN, THERESA (LPN)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:AUSTIN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1166 LAFAYETTE RD
Mailing Address - Street 2:D11
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-2481
Mailing Address - Country:US
Mailing Address - Phone:330-722-7488
Mailing Address - Fax:
Practice Address - Street 1:1166 LAFAYETTE RD
Practice Address - Street 2:D11
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-2481
Practice Address - Country:US
Practice Address - Phone:330-722-7488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-13
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.130717-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse