Provider Demographics
NPI:1760057392
Name:PROUD, BAILEE NICOLE
Entity Type:Individual
Prefix:
First Name:BAILEE
Middle Name:NICOLE
Last Name:PROUD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19800 N 7TH ST APT 1073
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85024-1886
Mailing Address - Country:US
Mailing Address - Phone:602-743-0930
Mailing Address - Fax:
Practice Address - Street 1:19800 N 7TH ST APT 1073
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85024-1886
Practice Address - Country:US
Practice Address - Phone:602-743-0930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program