MEDICARE: BERNETA MARIE TERRY RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WC1500X	Community Health Registered Nurse	22372617	NY

General Provider Information

NPI Number	:	1265685861
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BERNETA MARIE TERRY RN

Provider Business Mailing Address
First Line	:	4 HILLVIEW DR
Second Line	:
City	:	UNION SPRINGS
State	:	NY
Zip	:	13160-3109
Country	:	US
Telephone Number	:	315-889-9023
Fax Number	:

Provider Business Practice Location Address
First Line	:	4 HILLVIEW DR
Second Line	:
City	:	UNION SPRINGS
State	:	NY
Zip	:	13160-3109
Country	:	US
Telephone Number	:	315-889-9023
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/28/2008
Last Update Date	:	10/28/2008

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