Provider Demographics
NPI:1174130363
Name:TERRY, MARY JALENE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JALENE
Last Name:TERRY
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 1:16813 TOWNSHIP ROAD 55
Mailing Address - Street 2:
Mailing Address - City:BELLE CENTER
Mailing Address - State:OH
Mailing Address - Zip Code:43310-9664
Mailing Address - Country:US
Mailing Address - Phone:937-441-9484
Mailing Address - Fax:
Practice Address - Street 1:799 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-1519
Practice Address - Country:US
Practice Address - Phone:419-229-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH392993163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Single Specialty