Provider Demographics
NPI:1225129992
Name:BAUCUM, DONNA L (FNP)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:L
Last Name:BAUCUM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:MS
Mailing Address - Zip Code:39153-6016
Mailing Address - Country:US
Mailing Address - Phone:601-782-9797
Mailing Address - Fax:601-782-9790
Practice Address - Street 1:234 MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:MS
Practice Address - Zip Code:39153-6016
Practice Address - Country:US
Practice Address - Phone:601-782-9797
Practice Address - Fax:601-782-9790
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR544019363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04174306Medicaid