Provider Demographics
NPI:1841310968
Name:KING, TERESA (ANP, GNP, FNP)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:ANP, GNP, FNP
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP
Mailing Address - Street 1:4974 MANCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2010
Mailing Address - Country:US
Mailing Address - Phone:314-289-6566
Mailing Address - Fax:314-289-6566
Practice Address - Street 1:4974 MANCHESTER AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2010
Practice Address - Country:US
Practice Address - Phone:314-289-6566
Practice Address - Fax:314-289-6566
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO146904363L00000X
IL209-006077363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209-006077OtherIL APN LICENSE
IL041-330101OtherIL RN LICENSE