Healthcare Provider Details

I. General information

NPI: 1164834362
Provider Name (Legal Business Name): MARICYL TERRY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2014
Last Update Date: 05/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 LAKELAND DR STE 950
JACKSON MS
39216-4608
US

IV. Provider business mailing address

129 SARA FOX DR
BRANDON MS
39047-5527
US

V. Phone/Fax

Practice location:
  • Phone: 601-982-7811
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberR859763
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: