1598044976 NPI number — PAMELA RAE BAILEY

Table of content: PAMELA RAE BAILEY (NPI 1598044976)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598044976 NPI number — PAMELA RAE BAILEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAILEY
Provider First Name:
PAMELA
Provider Middle Name:
RAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1598044976
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
116 JACK JONES RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINNSBORO
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71295-6616
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2106-A LOOP ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WIINNSBORO
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71295
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-435-6363
Provider Business Practice Location Address Fax Number:
318-435-4646
Provider Enumeration Date:
08/16/2011

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: 363LP0200X , with the licence number:  RN-114742-AP06631 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2169904 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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