Provider Demographics
NPI:1780724666
Name:TETER, MARTHA (CRNP)
Entity type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:
Last Name:TETER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3334 DARBYSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45440-3672
Mailing Address - Country:US
Mailing Address - Phone:937-427-2027
Mailing Address - Fax:
Practice Address - Street 1:359 FOREST AVE STE 203
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-4559
Practice Address - Country:US
Practice Address - Phone:937-226-7414
Practice Address - Fax:937-226-1682
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-02174363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2103799Medicaid