Healthcare Provider Details

I. General information

NPI: 1942922414
Provider Name (Legal Business Name): BAYLEE KAY BURRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2022
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 SW 2ND ST
WALNUT RIDGE AR
72476-2603
US

IV. Provider business mailing address

602 SW 2ND ST
WALNUT RIDGE AR
72476-2603
US

V. Phone/Fax

Practice location:
  • Phone: 870-759-1679
  • Fax:
Mailing address:
  • Phone: 870-759-1679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: