Healthcare Provider Details

I. General information

NPI: 1578851325
Provider Name (Legal Business Name): TANDALAYA M TRAYLOR NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TANDALAYA M HARRIS RN

II. Dates (important events)

Enumeration Date: 07/14/2011
Last Update Date: 08/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 S GLOSTER ST
TUPELO MS
38801-4934
US

IV. Provider business mailing address

5410 MARYLAND WAY STE 300
BRENTWOOD TN
37027-5339
US

V. Phone/Fax

Practice location:
  • Phone: 662-377-2531
  • Fax: 662-377-2920
Mailing address:
  • Phone: 615-371-5744
  • Fax: 888-241-1404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR869243
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR869243
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: