Provider Demographics
NPI:1932565132
Name:DELONG, TERA CHARLENE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:TERA
Middle Name:CHARLENE
Last Name:DELONG
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:TERA
Other - Middle Name:CHARLENE
Other - Last Name:WILBUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:8071 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-9729
Mailing Address - Country:US
Mailing Address - Phone:315-378-9771
Mailing Address - Fax:
Practice Address - Street 1:8071 RIVER RD
Practice Address - Street 2:
Practice Address - City:BALDWINSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13027-9729
Practice Address - Country:US
Practice Address - Phone:315-378-9771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-05
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY292437164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse