Provider Demographics
NPI:1720806839
Name:DURHAM, TEYA
Entity type:Individual
Prefix:
First Name:TEYA
Middle Name:
Last Name:DURHAM
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 1:130 S WILLOW ST STE 9
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-9107
Mailing Address - Country:US
Mailing Address - Phone:907-935-3084
Mailing Address - Fax:
Practice Address - Street 1:130 S WILLOW ST STE 9
Practice Address - Street 2:
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-9107
Practice Address - Country:US
Practice Address - Phone:907-935-3084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK17123593747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant