Provider Demographics
NPI:1457366163
Name:TERRELL, WANDA KEEFE (PTA LMBT)
Entity Type:Individual
Prefix:MS
First Name:WANDA
Middle Name:KEEFE
Last Name:TERRELL
Suffix:
Gender:F
Credentials:PTA LMBT
Other - Prefix:MS
Other - First Name:WANDA
Other - Middle Name:MARIE
Other - Last Name:TERRELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA LMBT
Mailing Address - Street 1:909 DOCK STREET
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401
Mailing Address - Country:US
Mailing Address - Phone:910-352-5459
Mailing Address - Fax:
Practice Address - Street 1:2716 ASHTON DRIVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-2489
Practice Address - Country:US
Practice Address - Phone:910-352-5459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2228225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant