Provider Demographics
NPI:1568732188
Name:RAYBORN, NATHANIEL WAYLON (FNP-C)
Entity Type:Individual
Prefix:MR
First Name:NATHANIEL
Middle Name:WAYLON
Last Name:RAYBORN
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15077 WARREN DR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4555
Mailing Address - Country:US
Mailing Address - Phone:228-831-1522
Mailing Address - Fax:228-831-1522
Practice Address - Street 1:150 REYNOIR ST
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39530-4130
Practice Address - Country:US
Practice Address - Phone:228-432-1571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR859441363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily