Provider Demographics
NPI:1811079544
Name:BAXTER, DEBRA B (FNP-BC)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:B
Last Name:BAXTER
Suffix:
Gender:F
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 1:2918 LOUIS SESSIONS ST
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:71653-6049
Mailing Address - Country:US
Mailing Address - Phone:870-265-5343
Mailing Address - Fax:870-265-5686
Practice Address - Street 1:14116 CUSTOMS BLVD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-5164
Practice Address - Country:US
Practice Address - Phone:833-362-6703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004596363L00000X
MSR852798363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00125904Medicaid
AR465198ZHOWMedicare PIN