Provider Demographics
NPI:1972812527
Name:LINNEMAN, TERESA
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:LINNEMAN
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 1:209 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTE
Mailing Address - State:MO
Mailing Address - Zip Code:65248-1403
Mailing Address - Country:US
Mailing Address - Phone:660-248-1445
Mailing Address - Fax:
Practice Address - Street 1:500 E LIBERTY ST
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-2970
Practice Address - Country:US
Practice Address - Phone:660-248-1445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO625021803Medicaid
MO1308760001Medicare NSC