Provider Demographics
NPI:1346898285
Name:TERRY-BALL, GWENETH SUSAN
Entity Type:Individual
Prefix:
First Name:GWENETH
Middle Name:SUSAN
Last Name:TERRY-BALL
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 1:612 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:OK
Mailing Address - Zip Code:74743-4025
Mailing Address - Country:US
Mailing Address - Phone:580-326-2000
Mailing Address - Fax:589-326-2201
Practice Address - Street 1:612 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:OK
Practice Address - Zip Code:74743-4025
Practice Address - Country:US
Practice Address - Phone:580-326-2200
Practice Address - Fax:580-326-2201
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist