Healthcare Provider Details

I. General information

NPI: 1538087903
Provider Name (Legal Business Name): KRISTIN TERRELL
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 N MAIN ST
MADISON GA
30650-1312
US

IV. Provider business mailing address

1450 BINFORD RD
NEWBORN GA
30056-2513
US

V. Phone/Fax

Practice location:
  • Phone: 706-389-4313
  • Fax:
Mailing address:
  • Phone: 678-787-9449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN242407
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: