Provider Demographics
NPI:1780713461
Name:ECONOMOU, THERESA FAITH (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:FAITH
Last Name:ECONOMOU
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6306
Mailing Address - Fax:
Practice Address - Street 1:1025 VERDAE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-4032
Practice Address - Country:US
Practice Address - Phone:864-242-4683
Practice Address - Fax:864-240-5028
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201404814NP-PP363LA2200X
NYF301965363LA2200X
SC3125363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR201404814NP-PPOtherADULT NURSE PRACTITIONER
OR201403477 RNOtherRN
SCNP1489Medicaid
SC3125RXOtherADVANCED PRACTICE RN
SC3125RXOtherADVANCED PRACTICE RN
SCNP1489Medicaid
OR201404814NP-PPOtherADULT NURSE PRACTITIONER