Provider Demographics
NPI:1295239903
Name:MOAK, TERRI LEA (LVN)
Entity type:Individual
Prefix:
First Name:TERRI
Middle Name:LEA
Last Name:MOAK
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 OVERCREST DR
Mailing Address - Street 2:
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76126-4021
Mailing Address - Country:US
Mailing Address - Phone:817-247-2805
Mailing Address - Fax:
Practice Address - Street 1:120 OVERCREST DR
Practice Address - Street 2:
Practice Address - City:BENBROOK
Practice Address - State:TX
Practice Address - Zip Code:76126-4021
Practice Address - Country:US
Practice Address - Phone:817-905-5125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-19
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX88776164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse