Healthcare Provider Details

I. General information

NPI: 1699719534
Provider Name (Legal Business Name): TERRY D DURHAM CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 08/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 W GUM ST
MARION KY
42064-1516
US

IV. Provider business mailing address

PO BOX 386
MARION KY
42064-0386
US

V. Phone/Fax

Practice location:
  • Phone: 270-965-5281
  • Fax: 270-965-4852
Mailing address:
  • Phone: 270-965-5281
  • Fax: 270-965-4852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1069081
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: