Provider Demographics
NPI:1902181332
Name:TERRY, OCTAVIA (RN)
Entity Type:Individual
Prefix:
First Name:OCTAVIA
Middle Name:
Last Name:TERRY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2311 OLD HAROLD RD APT L256
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550-7522
Mailing Address - Country:US
Mailing Address - Phone:310-866-0338
Mailing Address - Fax:
Practice Address - Street 1:2311 OLD HAROLD RD APT L256
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-7522
Practice Address - Country:US
Practice Address - Phone:310-866-0338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA802131163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse