Provider Demographics
NPI:1316483514
Name:GOURLEY, TERI (LPN)
Entity type:Individual
Prefix:
First Name:TERI
Middle Name:
Last Name:GOURLEY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 DAWSON ST
Mailing Address - Street 2:
Mailing Address - City:VONORE
Mailing Address - State:TN
Mailing Address - Zip Code:37385
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 DAWSON ST
Practice Address - Street 2:
Practice Address - City:VONORE
Practice Address - State:TN
Practice Address - Zip Code:37385
Practice Address - Country:US
Practice Address - Phone:423-884-3180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-11
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN81966164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN81966OtherNURSING LICENSE