Healthcare Provider Details

I. General information

NPI: 1023044948
Provider Name (Legal Business Name): LATEFA NICHELLE TERRY PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 W VILLANOW ST
LA FAYETTE GA
30728-2463
US

IV. Provider business mailing address

4519 LOCKSLEY LN
CHATTANOOGA TN
37416-2913
US

V. Phone/Fax

Practice location:
  • Phone: 706-638-5983
  • Fax:
Mailing address:
  • Phone: 423-490-1295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number6870
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: