Provider Demographics
NPI:1346606753
Name:KUSSEROW, TERRANCE (RNWCC)
Entity Type:Individual
Prefix:
First Name:TERRANCE
Middle Name:
Last Name:KUSSEROW
Suffix:
Gender:M
Credentials:RNWCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 WEST HIGHWAY 22
Mailing Address - Street 2:
Mailing Address - City:SANTO DOMINGO PUEBLO
Mailing Address - State:NM
Mailing Address - Zip Code:87052
Mailing Address - Country:US
Mailing Address - Phone:505-465-3060
Mailing Address - Fax:
Practice Address - Street 1:85 WEST HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:SANTO DOMINGO PUEBLO
Practice Address - State:NM
Practice Address - Zip Code:87052
Practice Address - Country:US
Practice Address - Phone:505-465-3060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-14
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR52166163WW0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WW0000XNursing Service ProvidersRegistered NurseWound Care