Provider Demographics
NPI:1316949050
Name:DUFFY, THERESA MARIE (CRNA)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:DUFFY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5385 WAHLSTEN RD
Mailing Address - Street 2:
Mailing Address - City:EMBARRASS
Mailing Address - State:MN
Mailing Address - Zip Code:55732-8613
Mailing Address - Country:US
Mailing Address - Phone:218-984-2230
Mailing Address - Fax:
Practice Address - Street 1:901 9TH ST N
Practice Address - Street 2:
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792-2348
Practice Address - Country:US
Practice Address - Phone:218-749-9457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR142887-2367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL954000Medicare ID - Type Unspecified