Basic Information
| Provider Information | |||||||||
| NPI: | 1780649962 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERRICK | ||||||||
| FirstName: | TERRY | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TIPPETT | ||||||||
| OtherFirstName: | TERRY | ||||||||
| OtherMiddleName: | E | ||||||||
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| OtherCredential: | APRN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 950202 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402950202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 HUSTON DR | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | SHEPHERDSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 401657250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5029557311 | ||||||||
| FaxNumber: | 5029559694 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 03/08/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 3000979 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 009116 | 01 | KY | SIHO - CMA | OTHER | 000000350671 | 01 | KY | ANTHEM - DMA | OTHER | 000052154A | 01 | KY | HUMANA - CMA | OTHER | 1130950 | 01 | KY | PASSPORT - CMA | OTHER | 2437655000 | 01 | KY | PASSPORT ADVANTAGE - NMA | OTHER | 78001435 | 05 | KY | MEDICAID | 1192436 | 01 | KY | CHA - CMA | OTHER |