Healthcare Provider Details

I. General information

NPI: 1730110693
Provider Name (Legal Business Name): TERRYE MASTIN APRN,BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 02/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5625 POPLAR AVE
MEMPHIS TN
38119-3816
US

IV. Provider business mailing address

5625 POPLAR AVE
MEMPHIS TN
38119-3816
US

V. Phone/Fax

Practice location:
  • Phone: 901-761-1220
  • Fax: 901-763-4332
Mailing address:
  • Phone: 901-761-1220
  • Fax: 901-763-4332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberAPN6208
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License NumberTN6208
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: