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General NPI Number Information
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NPI Number | 1386450443
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Entity Type | Individual
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Provider Name | LAILANI BAILON MCCLELLAN FNP-C
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Gender | Female
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Dates
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Enumeration Date | 12/04/2024
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Last Update Date | 12/06/2024
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Provider Practice Location Address
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Address Line | 202 W GORDON ST STE A
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City | VALDOSTA
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State | GA
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Zip | 31601-4565
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Country | US
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Telephone | 229-474-4101
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Fax |
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Provider Business Mailing Address
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Address Line | 4285 CONWAY CIR
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City | VALDOSTA
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State | GA
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Zip | 31605-4410
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Country | US
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Telephone | 229-588-9268
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 138801
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License Number State | GA
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