Provider Demographics
NPI:1053581744
Name:TERRELL CLINIC LLC
Entity type:Organization
Organization Name:TERRELL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RENEA
Authorized Official - Middle Name:NAGEL
Authorized Official - Last Name:TERRELL
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP
Authorized Official - Phone:731-885-9687
Mailing Address - Street 1:701 E REELFOOT AVE STE 100
Mailing Address - Street 2:PO BOX 398
Mailing Address - City:UNION CITY
Mailing Address - State:TN
Mailing Address - Zip Code:38261-5886
Mailing Address - Country:US
Mailing Address - Phone:731-885-9687
Mailing Address - Fax:731-885-6643
Practice Address - Street 1:701 EAST REELFOOT AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261
Practice Address - Country:US
Practice Address - Phone:731-885-9687
Practice Address - Fax:731-885-6643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN92056363LF0000X
TNAPN6675363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1619977584OtherINDIVIDUAL NPI
TN1801193297OtherMELISSA REEVES NPI
TN1054900Medicaid
TN39081342Medicare PIN
TN1801193297OtherMELISSA REEVES NPI