Basic Information
| Provider Information | |||||||||
| NPI: | 1215650478 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TETER | ||||||||
| FirstName: | MAKENZIE | ||||||||
| MiddleName: | ANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1739 MUIFIELD DR | ||||||||
| Address2: | |||||||||
| City: | NEW LENOX | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153864432 | ||||||||
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| Practice Location | |||||||||
| Address1: | 901 MACARTHUR BLVD | ||||||||
| Address2: | |||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463212901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198361600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2022 | ||||||||
| LastUpdateDate: | 10/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WE0003X | 28277211A | IN | N | Nursing Service Providers | Registered Nurse | Emergency | 363L00000X | 71013157A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.