Provider Demographics
NPI:1467635839
Name:WATTERS, TERESA JOANNE
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:JOANNE
Last Name:WATTERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:
Other - Last Name:SLAGLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:744 S WEBSTER AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3505
Mailing Address - Country:US
Mailing Address - Phone:920-433-7411
Mailing Address - Fax:920-433-6090
Practice Address - Street 1:744 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3505
Practice Address - Country:US
Practice Address - Phone:920-433-7411
Practice Address - Fax:920-433-6090
Is Sole Proprietor?:No
Enumeration Date:2007-12-09
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3316-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
000026Medicare Oscar/Certification
WIP00771816Medicare Oscar/Certification
000048Medicare Oscar/Certification
WI000196Medicare Oscar/Certification
WI000001Medicare Oscar/Certification
WI000022Medicare Oscar/Certification
WI000033Medicare Oscar/Certification
WI000071Medicare Oscar/Certification
WI000040Medicare Oscar/Certification