Provider Demographics
NPI:1760994784
Name:MANNELLA, TERYN ELIZABETH (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TERYN
Middle Name:ELIZABETH
Last Name:MANNELLA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 OLD WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-7548
Mailing Address - Country:US
Mailing Address - Phone:304-590-2101
Mailing Address - Fax:
Practice Address - Street 1:196 THOMAS JOHNSON DR STE 135
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4518
Practice Address - Country:US
Practice Address - Phone:301-694-6688
Practice Address - Fax:301-694-8524
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC06627363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant