Provider Demographics
NPI:1194568188
Name:PATTERSON, THERESA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:PATTERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4664 VIENNA CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-5524
Mailing Address - Country:US
Mailing Address - Phone:229-333-8028
Mailing Address - Fax:
Practice Address - Street 1:4664 VIENNA CHURCH RD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-5524
Practice Address - Country:US
Practice Address - Phone:229-333-8028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCH008346311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home