Provider Demographics
NPI:1962037713
Name:CUNNINGHAM, TEROY
Entity Type:Individual
Prefix:
First Name:TEROY
Middle Name:
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:356 S YELLOW SPRINGS ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45506-1539
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:356 S YELLOW SPRINGS ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45506-1539
Practice Address - Country:US
Practice Address - Phone:937-460-7522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH492612Medicaid