Provider Demographics
NPI:1366510430
Name:BERTUCCI, TERESE M (APN)
Entity type:Individual
Prefix:
First Name:TERESE
Middle Name:M
Last Name:BERTUCCI
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 S 1ST AVE
Mailing Address - Street 2:FAHEY BLDG., ROOM 137
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-3328
Mailing Address - Country:US
Mailing Address - Phone:708-216-0160
Mailing Address - Fax:708-216-5285
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:FAHEY BLDG., ROOM 137
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-216-0160
Practice Address - Fax:708-216-5285
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-000449363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
S76758Medicare UPIN