Provider Demographics
NPI:1972772317
Name:BLANC, TERESA W (FNP)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:W
Last Name:BLANC
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:336 DEERFIELD RD
Mailing Address - Street 2:WATAUGA MEDICAL CENTER
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-5008
Mailing Address - Country:US
Mailing Address - Phone:828-262-4100
Mailing Address - Fax:828-262-4103
Practice Address - Street 1:336 DEERFIELD RD
Practice Address - Street 2:WATAUGA MEDICAL CENTER
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-5008
Practice Address - Country:US
Practice Address - Phone:828-262-4100
Practice Address - Fax:828-262-4103
Is Sole Proprietor?:No
Enumeration Date:2008-02-28
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO117415363L00000X
KY6298P363LF0000X
NC120564363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100103230Medicaid
MO425203502Medicaid
KY7100103230Medicaid