Healthcare Provider Details

I. General information

NPI: 1598905648
Provider Name (Legal Business Name): AMANDA TERRY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2009
Last Update Date: 03/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4109 HWY 98 WEST
SUMMIT MS
39666
US

IV. Provider business mailing address

8781 CHAPEL RD
MERIDIAN MS
39305-9646
US

V. Phone/Fax

Practice location:
  • Phone: 601-276-3900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA2989
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: