Provider Demographics
NPI:1275267262
Name:TERIET, MARIAH GLORIA
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:GLORIA
Last Name:TERIET
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 1:2808 EAST OUTER DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-5207
Mailing Address - Country:US
Mailing Address - Phone:618-993-3817
Mailing Address - Fax:
Practice Address - Street 1:2808 EAST OUTER DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5207
Practice Address - Country:US
Practice Address - Phone:618-993-3817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-14
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209025444363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner