Provider Demographics
NPI:1558793034
Name:PROVOST, TERRA L (ND)
Entity Type:Individual
Prefix:DR
First Name:TERRA
Middle Name:L
Last Name:PROVOST
Suffix:
Gender:F
Credentials:ND
Other - Prefix:DR
Other - First Name:TERRA
Other - Middle Name:
Other - Last Name:DALLMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ND
Mailing Address - Street 1:206 SHEYENNE DR
Mailing Address - Street 2:
Mailing Address - City:HORACE
Mailing Address - State:ND
Mailing Address - Zip Code:58047-4418
Mailing Address - Country:US
Mailing Address - Phone:218-303-9003
Mailing Address - Fax:888-651-4713
Practice Address - Street 1:1203 28TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-8711
Practice Address - Country:US
Practice Address - Phone:218-303-9003
Practice Address - Fax:888-651-4713
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-06
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13-1372175F00000X
CAND774175F00000X
ND2017-02175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath