Provider Demographics
NPI:1437238938
Name:BAIN, LAQUITA GAY (FNP)
Entity Type:Individual
Prefix:
First Name:LAQUITA
Middle Name:GAY
Last Name:BAIN
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 1:502 ALCORN DRIVE
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834
Mailing Address - Country:US
Mailing Address - Phone:662-287-5216
Mailing Address - Fax:662-287-8406
Practice Address - Street 1:100 NORMAN RD
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834
Practice Address - Country:US
Practice Address - Phone:662-287-6999
Practice Address - Fax:662-287-1709
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR850466363LF0000X
TN7259363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
P22125Medicare UPIN