Provider Demographics
NPI:1952436057
Name:RAFIQUE, THERESA ANN (APRN)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:ANN
Last Name:RAFIQUE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 COUNTY ROAD 352
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-7068
Mailing Address - Country:US
Mailing Address - Phone:662-455-8226
Mailing Address - Fax:
Practice Address - Street 1:2504 BROWNING ROAD 520
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-6022
Practice Address - Country:US
Practice Address - Phone:662-453-6211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR867386363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily