Individual
MARY TERRY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
RN
Contact information
Practice address
2600 GREENBUSH ST, LAFAYETTE, IN 47904-2477
(765) 448-8000
(765) 448-7624
Mailing address
PO BOX 5545, LAFAYETTE, IN 47903-5545
(765) 448-8000
(765) 448-8085
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
28177134A
IN
363LF0000X
Family Nurse Practitioner
Primary
71007565A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000001121068
ANTHEM PROVIDER NUMBER
IN
05
—
300007729
—
IN
Enumeration date
06/19/2017
Last updated
11/13/2017
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