Provider Demographics
NPI:1902128747
Name:BUCHANAN, THERESA KASSACK (NP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:KASSACK
Last Name:BUCHANAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 LAKE ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:GA
Mailing Address - Zip Code:31087-5022
Mailing Address - Country:US
Mailing Address - Phone:770-412-6880
Mailing Address - Fax:
Practice Address - Street 1:134 W CAMPUS DR
Practice Address - Street 2:CBX 091
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061
Practice Address - Country:US
Practice Address - Phone:478-445-5288
Practice Address - Fax:478-445-3142
Is Sole Proprietor?:No
Enumeration Date:2010-02-22
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN149616363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner