Healthcare Provider Details

I. General information

NPI: 1144555392
Provider Name (Legal Business Name): TERRI LEE PENCE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2009
Last Update Date: 11/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7073 CLYO RD
CENTERVILLE OH
45459-4816
US

IV. Provider business mailing address

7073 CLYO RD
CENTERVILLE OH
45459-4816
US

V. Phone/Fax

Practice location:
  • Phone: 937-435-5857
  • Fax: 937-912-4960
Mailing address:
  • Phone: 937-435-5857
  • Fax: 937-912-4960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN.281815
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCOA11087-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: