Basic Information
Provider Information
NPI: 1467730481
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: HOFFMAN
FirstName: TERA
MiddleName: JEAN
NamePrefix: MISS
NameSuffix:  
Credential: CSFA
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1604 VISA DR STE 2
Address2:  
City: NORMAL
State: IL
PostalCode: 617612195
CountryCode: US
TelephoneNumber: 3098464716
FaxNumber: 3093230441
Practice Location
Address1: 1604 VISA DR
Address2: STE 2
City: NORMAL
State: IL
PostalCode: 617612195
CountryCode: US
TelephoneNumber: 3098464716
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/25/2011
LastUpdateDate: 01/29/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
246ZS0410X125814MOY    

No ID Information.


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