Provider Demographics
NPI:1417460569
Name:HERZOG, TERRY D (RN)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:D
Last Name:HERZOG
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13650 W GRAHAM ST
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-2572
Mailing Address - Country:US
Mailing Address - Phone:262-938-9323
Mailing Address - Fax:
Practice Address - Street 1:1501 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-2461
Practice Address - Country:US
Practice Address - Phone:262-548-7986
Practice Address - Fax:262-970-4799
Is Sole Proprietor?:No
Enumeration Date:2017-11-12
Last Update Date:2017-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI79688-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse