Healthcare Provider Details

I. General information

NPI: 1245477694
Provider Name (Legal Business Name): TERRI ANNE WILLIS NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2009
Last Update Date: 06/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9105 FRANKLIN SQUARE DR
BALTIMORE MD
21237-3930
US

IV. Provider business mailing address

851 MANHATTAN AVE
BROOKLYN NY
11222-2539
US

V. Phone/Fax

Practice location:
  • Phone: 410-574-1330
  • Fax: 410-574-2691
Mailing address:
  • Phone: 718-752-7280
  • Fax: 718-752-1837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number304203
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR238735
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: