Provider Demographics
NPI:1174697882
Name:DEANE-DAUWALDER, TERRY L (FNP)
Entity type:Individual
Prefix:MS
First Name:TERRY
Middle Name:L
Last Name:DEANE-DAUWALDER
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 1:2710 GATEWAY OAKS DR # 360
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95833-3505
Mailing Address - Country:US
Mailing Address - Phone:916-646-2770
Mailing Address - Fax:
Practice Address - Street 1:2710 GATEWAY OAKS DR # 360
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95833-3505
Practice Address - Country:US
Practice Address - Phone:916-646-2770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13239163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA13239OtherLICENSE
CAP68622Medicare UPIN