Provider Demographics
NPI:1588188619
Name:BAXTER, MANDY KAY (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MANDY KAY
Middle Name:
Last Name:BAXTER
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:MANDY KAY
Other - Middle Name:
Other - Last Name:SHACKLEFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PMHNP-BC
Mailing Address - Street 1:3601 THE VANDERBILT CLINIC
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37232-5100
Mailing Address - Country:US
Mailing Address - Phone:615-322-3000
Mailing Address - Fax:
Practice Address - Street 1:1272 GARRISON DR STE 305
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-3175
Practice Address - Country:US
Practice Address - Phone:615-875-5770
Practice Address - Fax:615-877-1294
Is Sole Proprietor?:No
Enumeration Date:2017-07-31
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902146363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ032672Medicaid
MS08976882Medicaid