Provider Demographics
NPI:1710487723
Name:TERRAL, KERRY L (164X00000X)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:L
Last Name:TERRAL
Suffix:
Gender:F
Credentials:164X00000X
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1314 LAKE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-4582
Mailing Address - Country:US
Mailing Address - Phone:325-320-8301
Mailing Address - Fax:
Practice Address - Street 1:1301 SE 22ND AVE
Practice Address - Street 2:
Practice Address - City:MINERAL WELLS
Practice Address - State:TX
Practice Address - Zip Code:76067-6777
Practice Address - Country:US
Practice Address - Phone:940-468-2083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-16
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX311949164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX311949OtherTEXAS BON