Provider Demographics
NPI:1417540493
Name:EVERSOLE, TERRIE
Entity Type:Individual
Prefix:
First Name:TERRIE
Middle Name:
Last Name:EVERSOLE
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 1:715 HENRY W MILLER BLVD
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:WV
Mailing Address - Zip Code:25434-3111
Mailing Address - Country:US
Mailing Address - Phone:540-533-0115
Mailing Address - Fax:
Practice Address - Street 1:715 HENRY W MILLER BLVD
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:WV
Practice Address - Zip Code:25434-3111
Practice Address - Country:US
Practice Address - Phone:540-533-0115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker