Healthcare Provider Details

I. General information

NPI: 1306856166
Provider Name (Legal Business Name): LITA C BAILLY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LITA C BAILLY FNP

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 10/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 BONITA ST
GRANTS NM
87020-2103
US

IV. Provider business mailing address

1217 BONITA ST
GRANTS NM
87020-2103
US

V. Phone/Fax

Practice location:
  • Phone: 505-287-2950
  • Fax: 505-287-2403
Mailing address:
  • Phone: 505-287-2950
  • Fax: 505-287-2403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR029543
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP081328
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: