Provider Demographics
NPI:1609198209
Name:THARPE, TERESA SUDDRETH (GONP)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:SUDDRETH
Last Name:THARPE
Suffix:
Gender:F
Credentials:GONP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 PARKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ELKIN
Mailing Address - State:NC
Mailing Address - Zip Code:28621-2430
Mailing Address - Country:US
Mailing Address - Phone:336-835-5945
Mailing Address - Fax:
Practice Address - Street 1:150 PARKWOOD DR
Practice Address - Street 2:
Practice Address - City:ELKIN
Practice Address - State:NC
Practice Address - Zip Code:28621-2430
Practice Address - Country:US
Practice Address - Phone:336-835-5945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-23
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC800061363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1609198209Medicaid
NCNCS801AOtherMEDICARE PTAN