Provider Demographics
NPI:1720328412
Name:PEQUEEN, THERESA M (FNP)
Entity Type:Individual
Prefix:MISS
First Name:THERESA
Middle Name:M
Last Name:PEQUEEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DELEVAN
Mailing Address - State:NY
Mailing Address - Zip Code:14042-9501
Mailing Address - Country:US
Mailing Address - Phone:716-707-7040
Mailing Address - Fax:
Practice Address - Street 1:38 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DELEVAN
Practice Address - State:NY
Practice Address - Zip Code:14042-9501
Practice Address - Country:US
Practice Address - Phone:716-707-7040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-18
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF337625-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily