Healthcare Provider Details

I. General information

NPI: 1891743357
Provider Name (Legal Business Name): TERRY LYNN WARREN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 04/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9911 CORKSCREW RD. SUITE 101
ESTERO FL
33928
US

IV. Provider business mailing address

12550 PROFESSIONAL PARK DR. SUITE 11
FORT MYERS FL
33913
US

V. Phone/Fax

Practice location:
  • Phone: 239-768-2111
  • Fax: 239-482-4404
Mailing address:
  • Phone: 239-768-2111
  • Fax: 239-482-4404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberPA23282
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA23282
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA23282
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: