Provider Demographics
NPI:1467845131
Name:FAIRLEY, TERRIYON (RDN, LDN)
Entity type:Individual
Prefix:MS
First Name:TERRIYON
Middle Name:
Last Name:FAIRLEY
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3111 FLORIDA BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-3758
Mailing Address - Country:US
Mailing Address - Phone:225-650-2093
Mailing Address - Fax:225-615-8794
Practice Address - Street 1:3111 FLORIDA BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-3758
Practice Address - Country:US
Practice Address - Phone:225-650-2093
Practice Address - Fax:225-615-8794
Is Sole Proprietor?:No
Enumeration Date:2015-03-05
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2584133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered