Provider Demographics
NPI:1528710795
Name:TEAGUE, MWAJUMA DENISE
Entity type:Individual
Prefix:
First Name:MWAJUMA
Middle Name:DENISE
Last Name:TEAGUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1223 BOB KIRBY RD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37931-4802
Mailing Address - Country:US
Mailing Address - Phone:850-374-1082
Mailing Address - Fax:
Practice Address - Street 1:1001 COLLEGE BLVD W STE B1
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-1049
Practice Address - Country:US
Practice Address - Phone:850-252-4303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-19
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN270060163W00000X, 207Q00000X
FL11032445207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No163W00000XNursing Service ProvidersRegistered Nurse