Healthcare Provider Details

I. General information

NPI: 1467730481
Provider Name (Legal Business Name): TERA JEAN HOFFMAN CSFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2011
Last Update Date: 01/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1604 VISA DR STE 2
NORMAL IL
61761-2195
US

IV. Provider business mailing address

1604 VISA DR STE 2
NORMAL IL
61761-2195
US

V. Phone/Fax

Practice location:
  • Phone: 309-846-4716
  • Fax:
Mailing address:
  • Phone: 309-846-4716
  • Fax: 309-323-0441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number125814
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: