Provider Demographics
NPI:1285895201
Name:TETTERTON, LAURA JEAN KISTLER (NP)
Entity type:Individual
Prefix:MS
First Name:LAURA
Middle Name:JEAN KISTLER
Last Name:TETTERTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:LAURA
Other - Middle Name:JEAN
Other - Last Name:KISTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 3507
Mailing Address - Street 2:ERWIN ROAD
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27710-0001
Mailing Address - Country:US
Mailing Address - Phone:919-684-4117
Mailing Address - Fax:919-681-8563
Practice Address - Street 1:508 FULTON ST
Practice Address - Street 2:SURGICAL SERVICES (112)
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-3875
Practice Address - Country:US
Practice Address - Phone:919-416-5867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC084764363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health