Provider Demographics
NPI:1841459062
Name:HART, THERESA L (GNP, ANP)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:L
Last Name:HART
Suffix:
Gender:F
Credentials:GNP, ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6172 FAWN MEADOW ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:14425-1115
Mailing Address - Country:US
Mailing Address - Phone:585-329-1511
Mailing Address - Fax:
Practice Address - Street 1:6172 FAWN MEADOW ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NY
Practice Address - Zip Code:14425-1115
Practice Address - Country:US
Practice Address - Phone:585-329-1511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-03
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF340698-1363LG0600X
NY305553-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health