Provider Demographics
NPI:1700609617
Name:BAXLEY, ANNA JANE
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:JANE
Last Name:BAXLEY
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 1:181 LIVING INN CT
Mailing Address - Street 2:
Mailing Address - City:PROSPERITY
Mailing Address - State:SC
Mailing Address - Zip Code:29127-9180
Mailing Address - Country:US
Mailing Address - Phone:803-509-4806
Mailing Address - Fax:
Practice Address - Street 1:146 E HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4800
Practice Address - Country:US
Practice Address - Phone:803-314-9640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-07
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5718363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program