Provider Demographics
NPI:1346225257
Name:TERRELL, ILENE SH (DPM)
Entity Type:Individual
Prefix:DR
First Name:ILENE
Middle Name:SH
Last Name:TERRELL
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12010 KILARNEY DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407
Mailing Address - Country:US
Mailing Address - Phone:540-548-3668
Mailing Address - Fax:540-548-0019
Practice Address - Street 1:12010 KILARNEY DR
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407
Practice Address - Country:US
Practice Address - Phone:540-548-3668
Practice Address - Fax:540-548-0019
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103000702213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
528738OtherALLIANCE
214528OtherANTHEM
5413632891OtherCOM HEALTH-OPTIMA HLTHPPO
VA09302417Medicaid
5413633289OtherGEHA
528738OtherMAMSI
5413633289OtherGEHA