Provider Demographics
NPI:1093503773
Name:MAYBERRY, TERRI LYNN (FNP-BC)
Entity type:Individual
Prefix:
First Name:TERRI
Middle Name:LYNN
Last Name:MAYBERRY
Suffix:
Gender:
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-1519
Mailing Address - Country:US
Mailing Address - Phone:773-831-5021
Mailing Address - Fax:224-236-4900
Practice Address - Street 1:2145 E 170TH ST
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-3788
Practice Address - Country:US
Practice Address - Phone:708-895-3255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-30
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209032045363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily