Basic Information
| Provider Information | |||||||||
| NPI: | 1972772317 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLANC | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 336 DEERFIELD RD | ||||||||
| Address2: | WATAUGA MEDICAL CENTER | ||||||||
| City: | BOONE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286075008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282624100 | ||||||||
| FaxNumber: | 8282624103 | ||||||||
| Practice Location | |||||||||
| Address1: | 336 DEERFIELD RD | ||||||||
| Address2: | WATAUGA MEDICAL CENTER | ||||||||
| City: | BOONE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286075008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282624100 | ||||||||
| FaxNumber: | 8282624103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2008 | ||||||||
| LastUpdateDate: | 08/12/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 117415 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 6298P | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 120564 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 7100103230 | 05 | KY | MEDICAID | 425203502 | 05 | MO | MEDICAID |