Provider Demographics
NPI:1376304295
Name:ADDISON, KIYORO TERRIE
Entity Type:Individual
Prefix:MS
First Name:KIYORO
Middle Name:TERRIE
Last Name:ADDISON
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 1:6 HERITAGE RD
Mailing Address - Street 2:
Mailing Address - City:PORT WENTWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:31407-6019
Mailing Address - Country:US
Mailing Address - Phone:912-308-8238
Mailing Address - Fax:
Practice Address - Street 1:6 HERITAGE RD
Practice Address - Street 2:
Practice Address - City:PORT WENTWORTH
Practice Address - State:GA
Practice Address - Zip Code:31407-6019
Practice Address - Country:US
Practice Address - Phone:912-308-8238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide