Provider Demographics
NPI:1063104669
Name:TERRY, MAVIS (NP)
Entity type:Individual
Prefix:
First Name:MAVIS
Middle Name:
Last Name:TERRY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2326 W SAINT LOUIS ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-2639
Mailing Address - Country:US
Mailing Address - Phone:719-360-4503
Mailing Address - Fax:
Practice Address - Street 1:2326 W SAINT LOUIS ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-2639
Practice Address - Country:US
Practice Address - Phone:719-360-4503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11025250363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner