Basic Information
| Provider Information | |||||||||
| NPI: | 1588188619 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAXTER | ||||||||
| FirstName: | MANDY KAY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PMHNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHACKLEFORD | ||||||||
| OtherFirstName: | MANDY KAY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PMHNP-BC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3601 THE VANDERBILT CLINIC | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372325100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153223000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1272 GARRISON DR STE 305 | ||||||||
| Address2: | |||||||||
| City: | MURFREESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371293175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158755770 | ||||||||
| FaxNumber: | 6158771294 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2017 | ||||||||
| LastUpdateDate: | 11/25/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 902146 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | Q032672 | 05 | TN | MEDICAID | 08976882 | 05 | MS | MEDICAID |