Provider Demographics
NPI:1578162459
Name:TERRY, KOURTNEY MARIE (NP-C)
Entity Type:Individual
Prefix:
First Name:KOURTNEY
Middle Name:MARIE
Last Name:TERRY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 MINER RD
Mailing Address - Street 2:
Mailing Address - City:AVILLA
Mailing Address - State:IN
Mailing Address - Zip Code:46710-9690
Mailing Address - Country:US
Mailing Address - Phone:260-226-0388
Mailing Address - Fax:
Practice Address - Street 1:128 MINER RD
Practice Address - Street 2:
Practice Address - City:AVILLA
Practice Address - State:IN
Practice Address - Zip Code:46710-9690
Practice Address - Country:US
Practice Address - Phone:260-226-0388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-21
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INF10201135363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily