Provider Demographics
NPI:1144421694
Name:TERHARK, AIMEE J
Entity Type:Individual
Prefix:
First Name:AIMEE
Middle Name:J
Last Name:TERHARK
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 1:723 NE GLEN OAK AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3252
Mailing Address - Country:US
Mailing Address - Phone:309-624-8749
Mailing Address - Fax:309-624-8870
Practice Address - Street 1:7035 SAINT ANDREWS RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-1177
Practice Address - Country:US
Practice Address - Phone:803-749-0924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-006752363L00000X
SC28214363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
K44227Medicare PIN
IL809840Medicare ID - Type UnspecifiedGROUP #