Basic Information
Provider Information
NPI: 1033557319
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BAXLEY
FirstName: MEAGHAN
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: CRNP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: WINGARD
OtherFirstName: MEAGHAN
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType: 1
Mailing Information
Address1: 2055 E SOUTH BLVD
Address2: SUITE 601
City: MONTGOMERY
State: AL
PostalCode: 361162001
CountryCode: US
TelephoneNumber: 3342862999
FaxNumber:  
Practice Location
Address1: 2055 E SOUTH BLVD
Address2: SUITE 601
City: MONTGOMERY
State: AL
PostalCode: 361162001
CountryCode: US
TelephoneNumber: 3342862999
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/10/2013
LastUpdateDate: 06/10/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LF0000X1-118273ALY Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily

No ID Information.


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