Provider Demographics
NPI:1902991706
Name:TERRY, KENNY NMI (MD)
Entity Type:Individual
Prefix:MR
First Name:KENNY
Middle Name:NMI
Last Name:TERRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:358 N ISLAND DR
Mailing Address - Street 2:UNIT 101
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-9062
Mailing Address - Country:US
Mailing Address - Phone:901-237-0633
Mailing Address - Fax:
Practice Address - Street 1:6005 PARK AVE STE 630B
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5226
Practice Address - Country:US
Practice Address - Phone:901-767-1136
Practice Address - Fax:901-767-0476
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD403152084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1506871Medicaid