Healthcare Provider Details

I. General information

NPI: 1659025914
Provider Name (Legal Business Name): TERRAH MARIE SNYDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2022
Last Update Date: 02/07/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 NE GLEN OAK AVE
PEORIA IL
61636-8720
US

IV. Provider business mailing address

555 CAPITOL MALL STE 570
SACRAMENTO CA
95814-4502
US

V. Phone/Fax

Practice location:
  • Phone: 309-672-5522
  • Fax:
Mailing address:
  • Phone: 8-406-1120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.024777
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: