Provider Demographics
NPI:1912480955
Name:DEVINE, TERESA E (NP)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:E
Last Name:DEVINE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 MEXICO RD STE 101
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-1666
Mailing Address - Country:US
Mailing Address - Phone:636-442-5035
Mailing Address - Fax:636-442-5036
Practice Address - Street 1:4800 MEXICO RD STE 101
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1666
Practice Address - Country:US
Practice Address - Phone:636-442-5035
Practice Address - Fax:636-442-5036
Is Sole Proprietor?:No
Enumeration Date:2018-09-14
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017042803363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner