Provider Demographics
NPI:1134686116
Name:THERIAC, TRENT JIM-E (FNP-C)
Entity Type:Individual
Prefix:
First Name:TRENT
Middle Name:JIM-E
Last Name:THERIAC
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 PARR AVE
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-2033
Mailing Address - Country:US
Mailing Address - Phone:731-325-5678
Mailing Address - Fax:731-325-5679
Practice Address - Street 1:399 E HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261-8028
Practice Address - Country:US
Practice Address - Phone:731-592-0662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-26
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN210105163WE0003X
TN25562363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency