Provider Demographics
NPI:1497504450
Name:BAILEY, GENA RENEE (PTA)
Entity type:Individual
Prefix:
First Name:GENA
Middle Name:RENEE
Last Name:BAILEY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 ROAD 1850
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-7004
Mailing Address - Country:US
Mailing Address - Phone:662-871-9382
Mailing Address - Fax:
Practice Address - Street 1:1114 COMMONWEALTH BLVD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-9301
Practice Address - Country:US
Practice Address - Phone:662-840-6366
Practice Address - Fax:662-680-9797
Is Sole Proprietor?:No
Enumeration Date:2024-05-14
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA5301225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant