1316307366 NPI number — MRS. TERRICKA LATREASE BAILEY RN /APN

Table of content: MRS. TERRICKA LATREASE BAILEY RN /APN (NPI 1316307366)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316307366 NPI number — MRS. TERRICKA LATREASE BAILEY RN /APN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAILEY
Provider First Name:
TERRICKA
Provider Middle Name:
LATREASE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RN /APN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BAILEY
Provider Other First Name:
TERRICKA
Provider Other Middle Name:
L.
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
ACNP
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1316307366
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/03/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2363 LINDA SHORE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHAVEN
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38672-8382
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-955-1846
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4250 BETHEL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OLIVE BRANCH
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38654-8737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-932-9440
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/03/2016

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: 363LA2100X , with the licence number:  870475 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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