Provider Demographics
NPI:1063732949
Name:MUSTOVICH, TERESA (CNS)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:MUSTOVICH
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 PHILADELPHIA DR
Mailing Address - Street 2:SUITE 4505
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-1813
Mailing Address - Country:US
Mailing Address - Phone:937-434-4363
Mailing Address - Fax:937-734-4181
Practice Address - Street 1:2222 PHILADELPHIA DR
Practice Address - Street 2:SUITE 4505
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-1813
Practice Address - Country:US
Practice Address - Phone:937-434-4363
Practice Address - Fax:937-734-4181
Is Sole Proprietor?:No
Enumeration Date:2010-06-02
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA11184NS364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3090346Medicaid
OH3090346Medicaid