Provider Demographics
NPI:1316290752
Name:ROCKWELL, THERESA ANN (ADULT NP)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
Last Name:ROCKWELL
Suffix:
Gender:F
Credentials:ADULT NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14121 PARKE LONG CT STE 201
Mailing Address - Street 2:SUITE NO. 1080
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-1647
Mailing Address - Country:US
Mailing Address - Phone:855-247-1940
Mailing Address - Fax:844-379-5385
Practice Address - Street 1:14121 PARKE LONG CT STE 201
Practice Address - Street 2:SUITE NO. 1080
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-1647
Practice Address - Country:US
Practice Address - Phone:855-247-1940
Practice Address - Fax:844-379-5385
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-23
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.12839-NP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0081777Medicaid
OHH185680Medicare PIN