Provider Demographics
NPI:1508342767
Name:BAXLEY, TERESA GAIL (RN)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:GAIL
Last Name:BAXLEY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:GAIL
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:BARTOW
Mailing Address - State:FL
Mailing Address - Zip Code:33831-1559
Mailing Address - Country:US
Mailing Address - Phone:863-519-0575
Mailing Address - Fax:
Practice Address - Street 1:1255 GOLFVIEW AVE
Practice Address - Street 2:
Practice Address - City:BARTOW
Practice Address - State:FL
Practice Address - Zip Code:33830-6736
Practice Address - Country:US
Practice Address - Phone:863-519-0575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTN9343324163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse