Provider Demographics
NPI:1023506201
Name:DULLE, TERRY RAE (RN)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:RAE
Last Name:DULLE
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 1:801 W GORDON ST
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286-3426
Mailing Address - Country:US
Mailing Address - Phone:706-646-5725
Mailing Address - Fax:
Practice Address - Street 1:6274 33RD AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-2406
Practice Address - Country:US
Practice Address - Phone:715-271-3046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9470158163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL124995088OtherPINELLAS COUNTY VOTER ID CARD
FLD400816605850OtherSTATE OF FLORIDA DRIVERS LICENSE
FL9470158OtherRN MULTISTATE LICENSE