Provider Demographics
NPI:1124698402
Name:TERRY, AMANDA BETH
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:BETH
Last Name:TERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3433 ROACH RD
Mailing Address - Street 2:
Mailing Address - City:SALT ROCK
Mailing Address - State:WV
Mailing Address - Zip Code:25559-9508
Mailing Address - Country:US
Mailing Address - Phone:304-544-1871
Mailing Address - Fax:
Practice Address - Street 1:3433 ROACH RD
Practice Address - Street 2:
Practice Address - City:SALT ROCK
Practice Address - State:WV
Practice Address - Zip Code:25559-9508
Practice Address - Country:US
Practice Address - Phone:304-544-1871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant