Healthcare Provider Details

I. General information

NPI: 1144459652
Provider Name (Legal Business Name): TEKESHA LASHALL TERRY IDMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2009
Last Update Date: 07/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31ST MEDICAL GROUP UNIT 6180 BOX 245
APO AE
09604-0245
US

IV. Provider business mailing address

31ST MEDICAL GROUP UNIT 6180 BOX 245
APO AE
09604-0245
US

V. Phone/Fax

Practice location:
  • Phone: 01139434305692
  • Fax:
Mailing address:
  • Phone: 01139434305692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: