Healthcare Provider Details

I. General information

NPI: 1285010611
Provider Name (Legal Business Name): TERRA LYNN KLOTH CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2015
Last Update Date: 12/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6451 COME ABOUT WAY
AWENDAW SC
29429-6022
US

IV. Provider business mailing address

6451 COME ABOUT WAY
AWENDAW SC
29429-6022
US

V. Phone/Fax

Practice location:
  • Phone: 608-217-5503
  • Fax:
Mailing address:
  • Phone: 608-217-5503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number215418
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number19776
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: