Provider Demographics
NPI:1710158951
Name:CARLSON, TERA MICHELE (LPN)
Entity Type:Individual
Prefix:
First Name:TERA
Middle Name:MICHELE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:578 E GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45121-9035
Mailing Address - Country:US
Mailing Address - Phone:937-213-3611
Mailing Address - Fax:
Practice Address - Street 1:578 E GRANT AVE
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:OH
Practice Address - Zip Code:45121-9035
Practice Address - Country:US
Practice Address - Phone:937-213-3611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-16
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN115079164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse