Provider Demographics
NPI:1528502556
Name:BEKKALA, TERESA
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:BEKKALA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1960 SHENANDOAH CT UNIT B
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-6419
Mailing Address - Country:US
Mailing Address - Phone:612-226-5670
Mailing Address - Fax:
Practice Address - Street 1:14001 RIDGEDALE DR STE 100
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1781
Practice Address - Country:US
Practice Address - Phone:952-473-0211
Practice Address - Fax:952-473-7908
Is Sole Proprietor?:No
Enumeration Date:2016-12-09
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP 4828363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics