Basic Information
| Provider Information | |||||||||
| NPI: | 1215044235 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DENNIS | ||||||||
| FirstName: | TERRI | ||||||||
| MiddleName: | |||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCLIVE | ||||||||
| OtherFirstName: | TERRI | ||||||||
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| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5943 STADIUM DR | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490093016 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 601 S US 131 | ||||||||
| Address2: | |||||||||
| City: | THREE RIVERS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2692867070 | ||||||||
| FaxNumber: | 2692867071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 10/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704213605 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.