Provider Demographics
NPI:1164688891
Name:TERRY, STEPHANIE (CFNP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:TERRY
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 588
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-0588
Mailing Address - Country:US
Mailing Address - Phone:601-859-5213
Mailing Address - Fax:601-859-8771
Practice Address - Street 1:1668 W PEACE ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-5332
Practice Address - Country:US
Practice Address - Phone:601-859-5213
Practice Address - Fax:601-859-8771
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR866603363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSR866603OtherLICENSE NUMBER