Provider Demographics
NPI:1457645145
Name:SOPER, TERRY (NP)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:SOPER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 W KENWOOD AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4368
Mailing Address - Country:US
Mailing Address - Phone:217-876-2199
Mailing Address - Fax:217-876-2196
Practice Address - Street 1:102 W KENWOOD AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4368
Practice Address - Country:US
Practice Address - Phone:217-876-2199
Practice Address - Fax:217-876-2196
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-31
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209008819363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner