Provider Demographics
NPI:1134523830
Name:WILBANKS, RACHAEL J (NPC)
Entity type:Individual
Prefix:
First Name:RACHAEL
Middle Name:J
Last Name:WILBANKS
Suffix:
Gender:F
Credentials:NPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:601-200-5900
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:969 LAKELAND DRIVE
Practice Address - Street 2:ST. DOMINIC PALLIATIVE CARE
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-200-5900
Practice Address - Fax:601-200-0204
Is Sole Proprietor?:No
Enumeration Date:2014-10-09
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSF0814571363L00000X
MS884972363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1V8513OtherMEDICARE (ST DOM)
MS02505821Medicaid