Provider Demographics
NPI:1326316084
Name:SHED-BOOTH, TERRA
Entity Type:Individual
Prefix:
First Name:TERRA
Middle Name:
Last Name:SHED-BOOTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TERRA
Other - Middle Name:
Other - Last Name:SHED-BOOTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CSI, BA, PP
Mailing Address - Street 1:2831 E WYNNTON LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31906-2167
Mailing Address - Country:US
Mailing Address - Phone:706-332-2092
Mailing Address - Fax:
Practice Address - Street 1:2831 E WYNNTON LN
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31906-2167
Practice Address - Country:US
Practice Address - Phone:706-332-2092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-09
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker