Provider Demographics
NPI:1609575869
Name:YANCHUNIS, TERA
Entity Type:Individual
Prefix:
First Name:TERA
Middle Name:
Last Name:YANCHUNIS
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 1:725 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:WY
Mailing Address - Zip Code:82701-2930
Mailing Address - Country:US
Mailing Address - Phone:307-746-3553
Mailing Address - Fax:
Practice Address - Street 1:125 E WOLCOTT ST
Practice Address - Street 2:
Practice Address - City:NEWCASTLE
Practice Address - State:WY
Practice Address - Zip Code:82701-2203
Practice Address - Country:US
Practice Address - Phone:303-547-6362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY51731163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY110709-532OtherDIVER LICENSE