Provider Demographics
NPI:1750990222
Name:HART, THERESA MARIE (RN)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:HART
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:MARIE
Other - Last Name:FUNK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:505 S WASHBURN ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-7949
Mailing Address - Country:US
Mailing Address - Phone:920-232-2332
Mailing Address - Fax:920-232-2338
Practice Address - Street 1:505 S WASHBURN ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-7949
Practice Address - Country:US
Practice Address - Phone:920-232-2332
Practice Address - Fax:920-232-2338
Is Sole Proprietor?:No
Enumeration Date:2020-07-30
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI123093-30163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)