Provider Demographics
NPI:1942875174
Name:HUMPHRIES, TERRELL
Entity Type:Individual
Prefix:
First Name:TERRELL
Middle Name:
Last Name:HUMPHRIES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 CREST RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-5771
Mailing Address - Country:US
Mailing Address - Phone:912-259-5128
Mailing Address - Fax:
Practice Address - Street 1:65 W CAMPBELLTON ST
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-1338
Practice Address - Country:US
Practice Address - Phone:912-259-5128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide