Provider Demographics
NPI:1568654903
Name:TEAGUE, MALINDA (CPNP)
Entity type:Individual
Prefix:MS
First Name:MALINDA
Middle Name:
Last Name:TEAGUE
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5213 S ALSTON AVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-4430
Mailing Address - Country:US
Mailing Address - Phone:919-620-4855
Mailing Address - Fax:919-620-4921
Practice Address - Street 1:2406 BLUE RIDGE RD STE 100
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607
Practice Address - Country:US
Practice Address - Phone:919-786-5001
Practice Address - Fax:919-786-5051
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA250343363LP0200X
IL209-004496363LP0200X
NC5010373363L00000X
NC286171363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1568654903Medicaid