Provider Demographics
NPI:1790546133
Name:THOMPSON, BAILEY NICOLE
Entity type:Individual
Prefix:
First Name:BAILEY
Middle Name:NICOLE
Last Name:THOMPSON
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 1:169 MAPLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LOUISA
Mailing Address - State:KY
Mailing Address - Zip Code:41230-5730
Mailing Address - Country:US
Mailing Address - Phone:606-585-3747
Mailing Address - Fax:
Practice Address - Street 1:169 MAPLEWOOD DR
Practice Address - Street 2:
Practice Address - City:LOUISA
Practice Address - State:KY
Practice Address - Zip Code:41230-5730
Practice Address - Country:US
Practice Address - Phone:606-585-3747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-22
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5792363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC8060PAMedicaid