Provider Demographics
NPI:1598044976
Name:BAILEY, PAMELA RAE
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:RAE
Last Name:BAILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 JACK JONES RD
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71295-6616
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2106-A LOOP ROAD
Practice Address - Street 2:
Practice Address - City:WIINNSBORO
Practice Address - State:LA
Practice Address - Zip Code:71295
Practice Address - Country:US
Practice Address - Phone:318-435-6363
Practice Address - Fax:318-435-4646
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-16
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN-114742-AP06631363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2169904Medicaid