=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972748622
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAUNTINA M TERRY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2008
-----------------------------------------------------
Last Update Date | 12/10/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1316 SOMERVILLE RD SE SUITE 1
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35601-4305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-355-6105
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1315 13TH AVE SE
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35601-4308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-355-6105
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Registered Nurse
-----------------------------------------------------
License Number | 1-119207
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------