Healthcare Provider Details

I. General information

NPI: 1447797758
Provider Name (Legal Business Name): LIFTED CLINICAL PRACTICE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2017
Last Update Date: 09/08/2022
Certification Date: 09/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 RODEO RD STE C14
SANTA FE NM
87507-6503
US

IV. Provider business mailing address

2801 RODEO RD STE C14
SANTA FE NM
87507-6503
US

V. Phone/Fax

Practice location:
  • Phone: 505-430-0760
  • Fax: 866-354-3833
Mailing address:
  • Phone: 505-430-0760
  • Fax: 866-354-3833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License NumberAP123182
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number688447
License Number StateTX

VIII. Authorized Official

Name: DR. FUNMILAYO AINA
Title or Position: FAMILY NURSE PRACTITIONER
Credential: DNP,FNP-C
Phone: 505-430-0760