Provider Demographics
NPI:1780882266
Name:WALRATH, TERRIE JOY (LPN)
Entity type:Individual
Prefix:MRS
First Name:TERRIE
Middle Name:JOY
Last Name:WALRATH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:TERRIE
Other - Middle Name:JOY
Other - Last Name:FIFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:PO BOX 102
Mailing Address - Street 2:TERRIE WALRATH
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617
Mailing Address - Country:US
Mailing Address - Phone:315-379-9493
Mailing Address - Fax:315-379-9493
Practice Address - Street 1:771 HOWARDVILLE RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617
Practice Address - Country:US
Practice Address - Phone:315-386-1312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1814751164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02049998Medicaid