Provider Demographics
NPI:1174679518
Name:SWENSON, THERESA MARIE (APRN)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:SWENSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:MARIE
Other - Last Name:PETTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 843966
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3966
Mailing Address - Country:US
Mailing Address - Phone:573-884-3300
Mailing Address - Fax:573-884-0943
Practice Address - Street 1:205 PORTLAND ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6521
Practice Address - Country:US
Practice Address - Phone:573-884-6052
Practice Address - Fax:573-884-1151
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO117563363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO424840122Medicaid
MO794939OtherHEALTHLINK
MO424840122Medicaid
MO794939OtherHEALTHLINK
MO834205236Medicare PIN
MO152360074Medicare PIN