Provider Demographics
NPI:1699070433
Name:MAHAN-ETHERIDGE, TERESA K (ARNP)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:K
Last Name:MAHAN-ETHERIDGE
Suffix:
Gender:
Credentials:ARNP
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:K
Other - Last Name:MAHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:813-974-2201
Mailing Address - Fax:813-974-2812
Practice Address - Street 1:2 TAMPA GENERAL CIR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3603
Practice Address - Country:US
Practice Address - Phone:813-259-8700
Practice Address - Fax:813-259-8862
Is Sole Proprietor?:No
Enumeration Date:2011-01-25
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9208090363LN0000X, 363LN0000X
FLAPRN9208090363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY06M3OtherBLUE CROSS BLUE SHIELD
FL003148500Medicaid
FLEQ274ZMedicare PIN