Provider Demographics
NPI:1700437076
Name:RAYBURN, FRED ALLEN JR (FNP - BC)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:ALLEN
Last Name:RAYBURN
Suffix:JR
Gender:M
Credentials:FNP - BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4611 TOXISH RD
Mailing Address - Street 2:
Mailing Address - City:PONTOTOC
Mailing Address - State:MS
Mailing Address - Zip Code:38863-7080
Mailing Address - Country:US
Mailing Address - Phone:662-488-5658
Mailing Address - Fax:
Practice Address - Street 1:848 S MADISON ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4905
Practice Address - Country:US
Practice Address - Phone:662-844-4177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903556363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily