Provider Demographics
NPI:1548284391
Name:ROSSELLE, TERI LEE (FNP)
Entity type:Individual
Prefix:
First Name:TERI
Middle Name:LEE
Last Name:ROSSELLE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2461 SW PERKINS AVE
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-4301
Mailing Address - Country:US
Mailing Address - Phone:541-276-0250
Mailing Address - Fax:541-276-0253
Practice Address - Street 1:2461 SW PERKINS AVE
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-4301
Practice Address - Country:US
Practice Address - Phone:541-276-0250
Practice Address - Fax:541-276-0253
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30006540363L00000X
WARN00150128363L00000X
OR200350059NP363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9637703Medicaid
OR298484Medicaid
P99077Medicare UPIN
WAAB39575Medicare ID - Type Unspecified