Provider Demographics
NPI:1437683174
Name:RIDDICK, TERA
Entity Type:Individual
Prefix:DR
First Name:TERA
Middle Name:
Last Name:RIDDICK
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 1:107 XAVIER ST
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-3618
Mailing Address - Country:US
Mailing Address - Phone:601-310-9785
Mailing Address - Fax:
Practice Address - Street 1:107 XAVIER ST
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-3618
Practice Address - Country:US
Practice Address - Phone:601-310-9785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-19
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP136023363LF0000X, 363LP0808X
MI4704337467363LP0808X
NV847297363LP0808X
NM64961363LP0808X
IL277.001649363LP0808X
WAAP61207763363LP0808X
ID71519363LP0808X
KY3017193363LP0808X
FLAPRN11016385363LP0808X
NY403905363LP0808X
CA95008223363LP0808X
UT12410130-4405363LP0808X
VA0024182319363LP0808X
MS902065363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily