Provider Demographics
NPI:1336127190
Name:TERRELL, STEPHANIE (NP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:TERRELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2273 E GALA ST STE 110
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7289
Mailing Address - Country:US
Mailing Address - Phone:208-994-5700
Mailing Address - Fax:208-288-4339
Practice Address - Street 1:2273 E GALA ST
Practice Address - Street 2:STE. 110
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7289
Practice Address - Country:US
Practice Address - Phone:208-995-4449
Practice Address - Fax:208-288-4339
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP681A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010152588OtherBLUE SHIELD
IDNPWJ2OtherBLUE CROSS
IDNPWK0OtherBLUE CROSS
ID807287100Medicaid
ID000010152589OtherBLUE SHIELD
IDNPWJ2OtherBLUE CROSS
Q55174Medicare UPIN