Provider Demographics
NPI:1821696303
Name:GWALDIS, TERA J (APRN)
Entity Type:Individual
Prefix:MRS
First Name:TERA
Middle Name:J
Last Name:GWALDIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4570 COUNTY ROAD 13 S
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:FL
Mailing Address - Zip Code:32033-3402
Mailing Address - Country:US
Mailing Address - Phone:904-400-1678
Mailing Address - Fax:
Practice Address - Street 1:4570 COUNTY ROAD 13 S
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:FL
Practice Address - Zip Code:32033-3402
Practice Address - Country:US
Practice Address - Phone:904-400-1678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11009720363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily