Provider Demographics
NPI:1992982110
Name:TERRY, SHANA
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:
Last Name:TERRY
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 1:13912 OXNARD ST APT 9
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-3868
Mailing Address - Country:US
Mailing Address - Phone:303-916-2173
Mailing Address - Fax:
Practice Address - Street 1:13912 OXNARD ST APT 9
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-3868
Practice Address - Country:US
Practice Address - Phone:303-916-2173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA07719267174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist