Provider Demographics
NPI:1326860610
Name:TERRELL, DEZERAE PASSION (STNA)
Entity type:Individual
Prefix:
First Name:DEZERAE
Middle Name:PASSION
Last Name:TERRELL
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3745 CONFEDERATION DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43207-6578
Mailing Address - Country:US
Mailing Address - Phone:614-817-9574
Mailing Address - Fax:
Practice Address - Street 1:3745 CONFEDERATION DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43207-6578
Practice Address - Country:US
Practice Address - Phone:614-817-9574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH602403100522376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide