MEDICARE: KIESHIA TERRELL

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	163WG0000X	General Practice Registered Nurse	RN383678	OH

General Provider Information

NPI Number	:	1508495987
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIESHIA TERRELL

Provider Business Mailing Address
First Line	:	PO BOX 26096
Second Line	:
City	:	TROTWOOD
State	:	OH
Zip	:	45426-0096
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	94 W WOODBURY DR
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45415-2836
Country	:	US
Telephone Number	:	937-684-3600
Fax Number	:

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

Provider Enumeration Date	:	04/07/2020
Last Update Date	:	12/19/2020

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Directions to “ KIESHIA TERRELL ” Practice Location

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