Provider Demographics
NPI:1225037971
Name:BAILEY, NANCY THORNTON (PA)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:THORNTON
Last Name:BAILEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1957
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30459-1957
Mailing Address - Country:US
Mailing Address - Phone:912-839-2810
Mailing Address - Fax:912-839-2808
Practice Address - Street 1:1499 FAIR RD
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-1683
Practice Address - Country:US
Practice Address - Phone:912-839-2810
Practice Address - Fax:912-839-2808
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-15
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3998363A00000X
SC708363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP77089Medicaid
GA622193743CMedicaid
SCP77089Medicaid
GA97WCGDGMedicare ID - Type Unspecified