Provider Demographics
NPI:1144366683
Name:FUDGE, TERESA MARIE (RN)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:MARIE
Last Name:FUDGE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1318 NW 20TH AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-1671
Mailing Address - Country:US
Mailing Address - Phone:503-758-5450
Mailing Address - Fax:
Practice Address - Street 1:412 SW 12TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2329
Practice Address - Country:US
Practice Address - Phone:503-228-7134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR163WA0400X, 163WC1500X, 163WP0808X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health