Provider Demographics
NPI:1073149092
Name:KINNEY, TERRA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:TERRA
Middle Name:MARIE
Last Name:KINNEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TERRA
Other - Middle Name:MARIE
Other - Last Name:SCHARLACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2529
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 E ORANGE ST
Practice Address - Street 2:
Practice Address - City:HOOPESTON
Practice Address - State:IL
Practice Address - Zip Code:60942-1802
Practice Address - Country:US
Practice Address - Phone:217-283-5644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-21
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IL085007843363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant