Healthcare Provider Details

I. General information

NPI: 1912638255
Provider Name (Legal Business Name): TERRY LAMONT MOSLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2022
Last Update Date: 06/17/2022
Certification Date: 06/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 W 139TH ST APT 1A
NEW YORK NY
10031-7349
US

IV. Provider business mailing address

603 W 139TH ST APT 1A
NEW YORK NY
10031-7349
US

V. Phone/Fax

Practice location:
  • Phone: 201-793-2327
  • Fax:
Mailing address:
  • Phone: 215-833-0836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number791869283
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: