Provider Demographics
NPI:1285065292
Name:CONERLY, TERESA (NPC)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:CONERLY
Suffix:
Gender:F
Credentials:NPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 MCCRAY RD
Mailing Address - Street 2:
Mailing Address - City:JAYESS
Mailing Address - State:MS
Mailing Address - Zip Code:39641-8053
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:430 W BROAD ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MS
Practice Address - Zip Code:39654-7723
Practice Address - Country:US
Practice Address - Phone:601-825-7280
Practice Address - Fax:601-825-8130
Is Sole Proprietor?:No
Enumeration Date:2013-12-02
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR855066363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily