1407000425 NPI number — KELLY L TERRY CRNA

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407000425 NPI number — KELLY L TERRY CRNA

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

TERRY

Provider First Name:

KELLY

Provider Middle Name:

L

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

CRNA

Provider Gender Code:

F

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

WHEELER

Provider Other First Name:

KELLY

Provider Other Middle Name:

L

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

CRNA

Provider Other Last Name Type Code:

1

NPI Number:

1407000425

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

09/20/2019

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 841656

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

DALLAS

Provider Business Mailing Address State Name:

TX

Provider Business Mailing Address Postal Code:

75284-1656

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

903-531-5000

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

800 E DAWSON ST

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

TYLER

Provider Business Practice Location Address State Name:

TX

Provider Business Practice Location Address Postal Code:

75701-2036

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

903-531-5000

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

11/05/2008

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 367500000X , with the licence number:  695973 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 199841103 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 330659YN3X . This is a "MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 8329UE . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 8GY772 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 199841102 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 8A695U . This is a "BCBS OF TEXAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 75-1976930-005 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: P01290909 . This is a "RAIL ROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: TIN PLUS 015 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 199841105 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 75-2771569-008 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".