Provider Demographics
NPI:1376843458
Name:BALLARD, JIMMY E (APRN)
Entity Type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:E
Last Name:BALLARD
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:DANSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14437-9182
Mailing Address - Country:US
Mailing Address - Phone:585-335-5052
Mailing Address - Fax:585-335-5061
Practice Address - Street 1:45 MAPLE ST
Practice Address - Street 2:
Practice Address - City:DANSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14437-9182
Practice Address - Country:US
Practice Address - Phone:585-335-5052
Practice Address - Fax:585-335-5061
Is Sole Proprietor?:No
Enumeration Date:2010-10-24
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF431664-01363LA2100X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06525277Medicaid
AR188054758Medicaid