MEDICARE: LITA C BAILLY FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	R029543	ME
2	363LF0000X	Family Nurse Practitioner	AP081328	ME

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306856166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LITA C BAILLY FNP

Provider Business Mailing Address
First Line	:	1217 BONITA ST
Second Line	:
City	:	GRANTS
State	:	NM
Zip	:	87020-2103
Country	:	US
Telephone Number	:	505-287-2950
Fax Number	:	505-287-2403

Provider Business Practice Location Address
First Line	:	1217 BONITA ST
Second Line	:
City	:	GRANTS
State	:	NM
Zip	:	87020-2103
Country	:	US
Telephone Number	:	505-287-2950
Fax Number	:	505-287-2403

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2006
Last Update Date	:	10/27/2011

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Directions to “ LITA C BAILLY FNP” Practice Location

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