Provider Demographics
NPI:1962850446
Name:TERRY, BRENDA (PA-C)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:TERRY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4725 LEGACY COVE LN
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-2580
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4015 S COBB DR SE
Practice Address - Street 2:SUITE 115
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-6303
Practice Address - Country:US
Practice Address - Phone:770-431-2354
Practice Address - Fax:770-436-7143
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2588363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical