Provider Demographics
NPI:1528106408
Name:BAIZE, THERESA ELAINE (FNP, BC)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:ELAINE
Last Name:BAIZE
Suffix:
Gender:F
Credentials:FNP, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3207 COUNTRY CLUB DRIVE
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605
Mailing Address - Country:US
Mailing Address - Phone:229-242-8480
Mailing Address - Fax:229-251-0252
Practice Address - Street 1:3207 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-1029
Practice Address - Country:US
Practice Address - Phone:229-242-8480
Practice Address - Fax:229-241-0252
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA156046363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA261356861OtherTRICARE
GA261356861OtherTRICARE
GA50BBJNBMedicare ID - Type Unspecified