Provider Demographics
NPI:1023149481
Name:COREY, THERESA ROSE (APRN)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:ROSE
Last Name:COREY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-7100
Mailing Address - Fax:239-343-7190
Practice Address - Street 1:16271 BASS RD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908
Practice Address - Country:US
Practice Address - Phone:239-343-7100
Practice Address - Fax:239-343-7190
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9273971363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0402283OtherUNITED HEALTHCARE
FL014476200Medicaid
MA80807OtherFALLON
MANP2702OtherBLUE SHIELD