Basic Information
| Provider Information | |||||||||
| NPI: | 1174130363 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TERRY | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | JALENE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16813 TOWNSHIP ROAD 55 | ||||||||
| Address2: | |||||||||
| City: | BELLE CENTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433109664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374419484 | ||||||||
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| Practice Location | |||||||||
| Address1: | 799 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458041519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192292222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2020 | ||||||||
| LastUpdateDate: | 09/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WG0000X | 392993 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | General Practice |
No ID Information.