Healthcare Provider Details

I. General information

NPI: 1265014617
Provider Name (Legal Business Name): CHRISSY TERRY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2021
Last Update Date: 04/26/2021
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 W LA CADENA DR
RIVERSIDE CA
92501-1413
US

IV. Provider business mailing address

1021 W LA CADENA DR
RIVERSIDE CA
92501-1413
US

V. Phone/Fax

Practice location:
  • Phone: 951-784-8010
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number702204
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: