Healthcare Provider Details

I. General information

NPI: 1649520800
Provider Name (Legal Business Name): TANNISA D BAILEY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2012
Last Update Date: 07/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 HIGHWAY 138 SW
RIVERDALE GA
30296
US

IV. Provider business mailing address

1100 ETHANS WAY
MCDONOUGH GA
30252-8578
US

V. Phone/Fax

Practice location:
  • Phone: 770-907-4949
  • Fax: 770-907-4022
Mailing address:
  • Phone: 678-565-4677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN173039
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN173039
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: