Healthcare Provider Details

I. General information

NPI: 1992782304
Provider Name (Legal Business Name): TERESA RAYBOURN FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TERESA HOLIFIELD FNP-BC

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 10/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 WHITEOAK AVE
RALEIGH MS
39153-6082
US

IV. Provider business mailing address

PO BOX 24116
JACKSON MS
39225-4116
US

V. Phone/Fax

Practice location:
  • Phone: 601-825-7280
  • Fax: 601-825-8130
Mailing address:
  • Phone: 601-825-7280
  • Fax: 601-825-8130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR746931
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: