Provider Demographics
NPI:1538895057
Name:TERRY, SHELBY
Entity type:Individual
Prefix:
First Name:SHELBY
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 1:4521 LITTLE BULLSKIN RD
Mailing Address - Street 2:
Mailing Address - City:PATRIOT
Mailing Address - State:OH
Mailing Address - Zip Code:45658-9067
Mailing Address - Country:US
Mailing Address - Phone:740-256-6721
Mailing Address - Fax:
Practice Address - Street 1:4521 LITTLE BULLSKIN RD
Practice Address - Street 2:
Practice Address - City:PATRIOT
Practice Address - State:OH
Practice Address - Zip Code:45658-9067
Practice Address - Country:US
Practice Address - Phone:740-256-6721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0490280Medicaid