Provider Demographics
NPI:1710250055
Name:WALDROUP, TERA KAY (RN, APN, PMHNP)
Entity Type:Individual
Prefix:MRS
First Name:TERA
Middle Name:KAY
Last Name:WALDROUP
Suffix:
Gender:F
Credentials:RN, APN, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 PATRIOT WAY
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02632-1514
Mailing Address - Country:US
Mailing Address - Phone:214-718-0543
Mailing Address - Fax:
Practice Address - Street 1:94 MAIN ST
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-3146
Practice Address - Country:US
Practice Address - Phone:508-771-9599
Practice Address - Fax:508-771-1208
Is Sole Proprietor?:No
Enumeration Date:2012-02-16
Last Update Date:2012-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2278241363LP0808X
TX751298363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health