Provider Demographics
NPI:1720635162
Name:MINGLEDORFF, BAILEY
Entity type:Individual
Prefix:
First Name:BAILEY
Middle Name:
Last Name:MINGLEDORFF
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 1:361 TIMBER WAY E
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-3500
Mailing Address - Country:US
Mailing Address - Phone:678-910-0534
Mailing Address - Fax:
Practice Address - Street 1:3024 HIDDEN FOREST CT UNIT 7115
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-3162
Practice Address - Country:US
Practice Address - Phone:404-626-3314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider