Provider Demographics
NPI:1780680975
Name:TERRY, VICKI (RN, PMHNP)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:
Last Name:TERRY
Suffix:
Gender:F
Credentials:RN, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4511 STONEWALL ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75401-5951
Mailing Address - Country:US
Mailing Address - Phone:903-454-7200
Mailing Address - Fax:903-454-7204
Practice Address - Street 1:4511 STONEWALL ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75401-5951
Practice Address - Country:US
Practice Address - Phone:903-454-7200
Practice Address - Fax:903-454-7204
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX644223363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX475165ZTE0Medicare PIN