Provider Demographics
NPI:1992782304
Name:RAYBOURN, TERESA (FNP-BC)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:RAYBOURN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:
Other - Last Name:HOLIFIELD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:PO BOX 24116
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-4116
Mailing Address - Country:US
Mailing Address - Phone:601-825-7280
Mailing Address - Fax:601-825-8130
Practice Address - Street 1:226 WHITEOAK AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:MS
Practice Address - Zip Code:39153-6082
Practice Address - Country:US
Practice Address - Phone:601-825-7280
Practice Address - Fax:601-825-8130
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR746931363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP00872423OtherRAILROAD MEDICARE
MS00119934Medicaid
MS00119934Medicaid
MS500001697Medicare PIN