Provider Demographics
NPI:1720189756
Name:LANDRUM, THERESA E (CRNP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:E
Last Name:LANDRUM
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 AVALON AVE
Mailing Address - Street 2:
Mailing Address - City:MUSCLE SHOALS
Mailing Address - State:AL
Mailing Address - Zip Code:35661-3164
Mailing Address - Country:US
Mailing Address - Phone:256-386-0808
Mailing Address - Fax:256-389-8904
Practice Address - Street 1:2400 AVALON AVE
Practice Address - Street 2:
Practice Address - City:MUSCLE SHOALS
Practice Address - State:AL
Practice Address - Zip Code:35661
Practice Address - Country:US
Practice Address - Phone:256-386-0808
Practice Address - Fax:256-389-8904
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1030759363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051119112OtherBLUECROSS
AL051538775Medicare PIN
S86606Medicare UPIN