Provider Demographics
NPI:1649520800
Name:BAILEY, TANNISA D (APRN)
Entity type:Individual
Prefix:MRS
First Name:TANNISA
Middle Name:D
Last Name:BAILEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 ETHANS WAY
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-8578
Mailing Address - Country:US
Mailing Address - Phone:678-565-4677
Mailing Address - Fax:
Practice Address - Street 1:1324 HIGHWAY 138 SW
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30296
Practice Address - Country:US
Practice Address - Phone:770-907-4949
Practice Address - Fax:770-907-4022
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN173039163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse