Provider Demographics
NPI:1912736612
Name:TERRELL, TAKILA
Entity type:Individual
Prefix:
First Name:TAKILA
Middle Name:
Last Name:TERRELL
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 1:361 COUNTY ROAD 222
Mailing Address - Street 2:
Mailing Address - City:SHUBUTA
Mailing Address - State:MS
Mailing Address - Zip Code:39360-9510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:361 COUNTY ROAD 222
Practice Address - Street 2:
Practice Address - City:SHUBUTA
Practice Address - State:MS
Practice Address - Zip Code:39360-9510
Practice Address - Country:US
Practice Address - Phone:769-317-4142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-31
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS337650164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse