Provider Demographics
NPI:1881228641
Name:BAXLEY, TEDDY D
Entity Type:Individual
Prefix:
First Name:TEDDY
Middle Name:D
Last Name:BAXLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:TED
Other - Middle Name:D
Other - Last Name:BAXLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11182 FARM ROAD 197
Mailing Address - Street 2:
Mailing Address - City:ARTHUR CITY
Mailing Address - State:TX
Mailing Address - Zip Code:75411-3306
Mailing Address - Country:US
Mailing Address - Phone:903-732-3031
Mailing Address - Fax:
Practice Address - Street 1:11182 FARM ROAD 197
Practice Address - Street 2:
Practice Address - City:ARTHUR CITY
Practice Address - State:TX
Practice Address - Zip Code:75411-3306
Practice Address - Country:US
Practice Address - Phone:903-732-3031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-02
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX876319163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health