Provider Demographics
NPI:1396120192
Name:BELISLE, TERRY CARSON
Entity type:Individual
Prefix:MR
First Name:TERRY
Middle Name:CARSON
Last Name:BELISLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 608
Mailing Address - Street 2:
Mailing Address - City:PENNINGTON GAP
Mailing Address - State:VA
Mailing Address - Zip Code:24277-0608
Mailing Address - Country:US
Mailing Address - Phone:276-546-2165
Mailing Address - Fax:276-546-9701
Practice Address - Street 1:20471 AZEN RD
Practice Address - Street 2:
Practice Address - City:DAMASCUS
Practice Address - State:VA
Practice Address - Zip Code:24236-4141
Practice Address - Country:US
Practice Address - Phone:276-388-3411
Practice Address - Fax:276-388-3732
Is Sole Proprietor?:No
Enumeration Date:2015-07-22
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001222794163W00000X
VA0024172789363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0024172789OtherBOARD OF NURSING
VA0001222794OtherBOARD OF NURSING