Provider Demographics
NPI:1194356063
Name:BUSH, TERESA YVONNE (LPN)
Entity type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:YVONNE
Last Name:BUSH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:TERESA
Other - Middle Name:YVONNE
Other - Last Name:OWENS, SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2400 W. MAIN ST. PATHFINDER PRESCHOOL
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72076
Mailing Address - Country:US
Mailing Address - Phone:501-982-0528
Mailing Address - Fax:501-982-1468
Practice Address - Street 1:2400 WEST MAIN ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076
Practice Address - Country:US
Practice Address - Phone:501-982-0528
Practice Address - Fax:501-982-1091
Is Sole Proprietor?:No
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARL013112164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse