1568091270 NPI number — TONI SHANTEL GORDON-BAILEY APRN

Table of content: TONI SHANTEL GORDON-BAILEY APRN (NPI 1568091270)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568091270 NPI number — TONI SHANTEL GORDON-BAILEY APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORDON-BAILEY
Provider First Name:
TONI
Provider Middle Name:
SHANTEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568091270
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9150
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PADUCAH
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42002-9150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-744-9600
Provider Business Mailing Address Fax Number:
270-744-8642

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
615 OLD SYMSONIA RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42025-5042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-527-4800
Provider Business Practice Location Address Fax Number:
270-527-4910
Provider Enumeration Date:
04/04/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  3014546 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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