Provider Demographics
NPI:1396250346
Name:GAVRILOS, TERRAH KOPPIE (APN, CNP)
Entity type:Individual
Prefix:MRS
First Name:TERRAH
Middle Name:KOPPIE
Last Name:GAVRILOS
Suffix:
Gender:F
Credentials:APN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 E DRURY LN
Mailing Address - Street 2:
Mailing Address - City:NORTH BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-2111
Mailing Address - Country:US
Mailing Address - Phone:229-415-1203
Mailing Address - Fax:847-234-1875
Practice Address - Street 1:925 SHERWOOD DR
Practice Address - Street 2:
Practice Address - City:LAKE BLUFF
Practice Address - State:IL
Practice Address - Zip Code:60044-2203
Practice Address - Country:US
Practice Address - Phone:847-234-1177
Practice Address - Fax:847-234-1875
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-12
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015215363LP0200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL309010634OtherAPN CONTROLLED SUBSTANCE
IL209105215OtherAPN
IL041374819OtherREGISTERED PROFESSIONAL NURSE
IL1396250346Medicaid