Provider Demographics
NPI:1447677836
Name:DORSEY, TERRY (NP)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:DORSEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 OHIO AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-7200
Mailing Address - Country:US
Mailing Address - Phone:662-624-2504
Mailing Address - Fax:662-624-4354
Practice Address - Street 1:510 HIGHWAY 322
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-4717
Practice Address - Country:US
Practice Address - Phone:662-624-4292
Practice Address - Fax:662-624-4354
Is Sole Proprietor?:No
Enumeration Date:2014-03-24
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR820198363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08156332Medicaid
MS08156332Medicaid