Provider Demographics
NPI:1770692048
Name:MCQUAIDE, THERESA LEE (ANP)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:LEE
Last Name:MCQUAIDE
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13065 OLD TESSON FERRY RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-3441
Mailing Address - Country:US
Mailing Address - Phone:314-543-5222
Mailing Address - Fax:
Practice Address - Street 1:13065 OLD TESSON FERRY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-3441
Practice Address - Country:US
Practice Address - Phone:314-543-5222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORN117389163WG0000X
IL041-331941163WG0000X
IL209-004439364S00000X
IL209-005264363LA2200X
MO117389363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL500027009Medicare PIN
MOP02010Medicare UPIN
IL202793Medicare PIN
MO500012417Medicare PIN
MO000080588Medicare PIN