Provider Demographics
NPI:1528498755
Name:TERRY, LORRIE (MS,RD,LD)
Entity type:Individual
Prefix:
First Name:LORRIE
Middle Name:
Last Name:TERRY
Suffix:
Gender:F
Credentials:MS,RD,LD
Other - Prefix:
Other - First Name:LORRIE
Other - Middle Name:
Other - Last Name:TERRY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS,RD,LD
Mailing Address - Street 1:76 TRACY LEIGH LN
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-6650
Mailing Address - Country:US
Mailing Address - Phone:270-559-0589
Mailing Address - Fax:
Practice Address - Street 1:2401 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1188
Practice Address - Country:US
Practice Address - Phone:618-997-5311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-25
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY1971133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered